| Element | Data |
|---|---|
| Patient Name | Juana Mariana Gonzales |
| Mother's Maiden Name | Maria Acosta |
| ID Number | 123456 987633 |
| Date/Time of Birth | 12/23/2009 |
| Administrative Sex | Female |
| Patient Address | 4345 Standish Way Stamford CT 06903 USA |
| Patient Address 1 | 325 Shorline Drive Stamford CT 06901 |
| Local Number | (203)555-1212 |
| Race | Other Race |
| Ethnic Group | Hispanic or Latino |
| Birth Order |
| Element | Data |
|---|---|
| Immunization Registry Status | A |
| Immunization Registry Status Effective Date | 07/01/2012 |
| Publicity Code | Reminder/Recall - any method |
| Publicity Code Effective Date | 07/01/2012 |
| Protection Indicator | |
| Protection Indicator Effective Date |
| Element | Data |
|---|---|
| Name | Joanna Merida Gonzales |
| Relationship | Grandparent |
| Address | 4345 Standish Way Stamford CT 06901 |
| Phone Number | (203)555-1212 |
| Element | Data |
|---|---|
| Administered Code | hepatitis B vaccine, pediatric or pediatric/adolescent dosage |
| Date/Time Start of Administration | 11/23/2009 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | Lisa Sirtis |
| Substance Lot Number | 6332FK33 |
| Substance Expiration Date | 12/14/2010 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Shoreline Hospital |
| Entered By | Lisa Sirtis |
| Ordered By | Jane Carter |
| Element | Data |
|---|---|
| Administered Code | hepatitis B vaccine, unspecified formulation |
| Date/Time Start of Administration | 01/15/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical Immunization |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 6352FK1 |
| Substance Expiration Date | 10/01/2010 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Administered Code | hepatitis B vaccine, pediatric or pediatric/adolescent dosage |
| Date/Time Start of Administration | 10/30/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6352FK24 |
| Substance Expiration Date | 08/31/2012 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified |
| Date/Time Start of Administration | 01/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS2341 |
| Substance Expiration Date | 11/30/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 03/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS2433 |
| Substance Expiration Date | 09/04/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 05/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS3255 |
| Substance Expiration Date | 12/01/2010 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Reaction | fever of >40.5C (105F) within 48 hours of dose |
| Element | Data |
|---|---|
| Administered Code | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 02/21/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS249 |
| Substance Expiration Date | 03/01/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 08/31/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from other provider |
| Administering Provider | Linda Casera |
| Substance Lot Number | D643QS8243 |
| Substance Expiration Date | 09/01/2014 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | J Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 01/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M54K9245 |
| Substance Expiration Date | 03/24/2010 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 03/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M55K3342 |
| Substance Expiration Date | 10/30/2010 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 05/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M75K4566 |
| Substance Expiration Date | 05/23/2010 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 02/21/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M53K5534 |
| Substance Expiration Date | 02/22/2011 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 01/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D333PV2431 |
| Substance Expiration Date | 10/04/2010 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 03/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D333PV4344 |
| Substance Expiration Date | 03/23/2010 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 02/21/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from other provider |
| Administering Provider | Linda Casera |
| Substance Lot Number | D335PV9644 |
| Substance Expiration Date | 02/22/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | J Rodriguez |
| Element | Data |
|---|---|
| Administered Code | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 05/19/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | Parental decision |
| Completion Status | RE |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Administered Code | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 01/21/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P243V3281 |
| Substance Expiration Date | 01/30/2010 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 03/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P343V8321 |
| Substance Expiration Date | 03/30/2010 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 05/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P853V2164 |
| Substance Expiration Date | 08/30/2010 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 02/21/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P853V58532 |
| Substance Expiration Date | 04/18/2011 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | rotavirus, live, monovalent vaccine |
| Date/Time Start of Administration | 01/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RV533 |
| Substance Expiration Date | 02/15/2010 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | rotavirus, live, monovalent vaccine |
| Date/Time Start of Administration | 03/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RV932 |
| Substance Expiration Date | 05/10/2010 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 09/25/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D8043IN8734 |
| Substance Expiration Date | 03/12/2011 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 10/27/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D8043IN8734 |
| Substance Expiration Date | 03/12/2011 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 10/02/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D9334IN9333 |
| Substance Expiration Date | 05/22/2012 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 10/15/2013 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from parents written record |
| Administering Provider | Gina Ricci |
| Substance Lot Number | 8L4B3423 |
| Substance Expiration Date | 07/01/2014 |
| Substance Manufacturer Name | MedImmune, LLC |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | Nasal |
| Administration Site | Bilateral Nares |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Gina Ricci |
| Element | Data |
|---|---|
| Administered Code | influenza, live, intranasal, quadrivalent |
| Date/Time Start of Administration | 07/15/2015 |
| Administered Amount | 0.2 |
| Administered Units | |
| Administration Notes | New immunization record |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 8L4B3521 |
| Substance Expiration Date | 08/15/2015 |
| Substance Manufacturer Name | MedImmune,LLC |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | Nasal |
| Administration Site | Bilateral Nares |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| VIS Publication Date | 08/19/2014 |
| VIS Presentation Date | 07/15/2015 |
| vaccine fund pgm elig cat | Not VFC elig |
| Element | Data |
|---|---|
| Administered Code | influenza, live, intranasal, quadrivalent |
| Date/Time Start of Administration | 11/04/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D9553IN2243 |
| Substance Expiration Date | 04/30/2012 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule |
| Date/Time Start of Administration | 11/23/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RT33 |
| Substance Expiration Date | 01/24/2012 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule |
| Date/Time Start of Administration | 05/23/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RT48 |
| Substance Expiration Date | 09/11/2012 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Code | measles, mumps, rubella, and varicella virus vaccine |
| Date/Time Start of Administration | 10/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | historical |
| Administering Provider | J Martinez |
| Substance Lot Number | 7W27V7491 |
| Substance Expiration Date | 12/15/2010 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Code | measles, mumps, rubella, and varicella virus vaccine |
| Date/Time Start of Administration | 11/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7W87V3452 |
| Substance Expiration Date | 04/13/2013 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Code | measles, mumps, rubella, and varicella virus vaccine |
| Date/Time Start of Administration | 07/15/2015 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | New immunization record |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 7W87V3687 |
| Substance Expiration Date | 07/15/2015 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| VIS Publication Date | 05/21/2010 |
| VIS Presentation Date | 07/15/2015 |
| vaccine fund pgm elig cat | Not VFC elig |
| Element | Data |
|---|---|
| Patient Name | Juana Mariana Gonzales |
| Mother's Maiden Name | Maria Acosta |
| ID Number | 123456 987633 |
| Date/Time of Birth | 12/23/2009 |
| Administrative Sex | Female |
| Patient Address | 4345 Standish Way Stamford CT 06903 USA |
| Patient Address 1 | 325 Shorline Drive Stamford CT 06901 |
| Local Number | (203)555-1212 |
| Race | Other Race |
| Ethnic Group | Hispanic or Latino |
| Birth Order |
| Element | Data |
|---|---|
| Immunization Registry Status | A |
| Immunization Registry Status Effective Date | 07/01/2012 |
| Publicity Code | Reminder/Recall - any method |
| Publicity Code Effective Date | 07/01/2012 |
| Protection Indicator | |
| Protection Indicator Effective Date |
| Element | Data |
|---|---|
| Name | Joanna Merida Gonzales |
| Relationship | Grandparent |
| Address | 4345 Standish Way Stamford CT 06901 |
| Phone Number | (203)555-1212 |
| Element | Data |
|---|---|
| Administered Code | hepatitis B vaccine, pediatric or pediatric/adolescent dosage |
| Date/Time Start of Administration | 11/23/2009 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | Lisa Sirtis |
| Substance Lot Number | 6332FK33 |
| Substance Expiration Date | 12/14/2010 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Shoreline Hospital |
| Entered By | Lisa Sirtis |
| Ordered By | Jane Carter |
| Element | Data |
|---|---|
| Administered Code | hepatitis B vaccine, unspecified formulation |
| Date/Time Start of Administration | 01/15/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical Immunization |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 6352FK1 |
| Substance Expiration Date | 10/01/2010 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Administered Code | hepatitis B vaccine, pediatric or pediatric/adolescent dosage |
| Date/Time Start of Administration | 10/30/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6352FK24 |
| Substance Expiration Date | 08/31/2012 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified |
| Date/Time Start of Administration | 01/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS2341 |
| Substance Expiration Date | 11/30/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 03/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS2433 |
| Substance Expiration Date | 09/04/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 05/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS3255 |
| Substance Expiration Date | 12/01/2010 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Reaction | fever of >40.5C (105F) within 48 hours of dose |
| Element | Data |
|---|---|
| Administered Code | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 02/21/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS249 |
| Substance Expiration Date | 03/01/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 08/31/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from other provider |
| Administering Provider | Linda Casera |
| Substance Lot Number | D643QS8243 |
| Substance Expiration Date | 09/01/2014 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | J Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 01/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M54K9245 |
| Substance Expiration Date | 03/24/2010 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 03/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M55K3342 |
| Substance Expiration Date | 10/30/2010 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 05/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M75K4566 |
| Substance Expiration Date | 05/23/2010 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 02/21/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M53K5534 |
| Substance Expiration Date | 02/22/2011 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 01/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D333PV2431 |
| Substance Expiration Date | 10/04/2010 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 03/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D333PV4344 |
| Substance Expiration Date | 03/23/2010 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 02/21/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from other provider |
| Administering Provider | Linda Casera |
| Substance Lot Number | D335PV9644 |
| Substance Expiration Date | 02/22/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | J Rodriguez |
| Element | Data |
|---|---|
| Administered Code | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 05/19/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | Parental decision |
| Completion Status | RE |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Administered Code | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 01/21/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P243V3281 |
| Substance Expiration Date | 01/30/2010 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 03/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P343V8321 |
| Substance Expiration Date | 03/30/2010 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 05/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P853V2164 |
| Substance Expiration Date | 08/30/2010 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 02/21/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P853V58532 |
| Substance Expiration Date | 04/18/2011 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | rotavirus, live, monovalent vaccine |
| Date/Time Start of Administration | 01/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RV533 |
| Substance Expiration Date | 02/15/2010 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | rotavirus, live, monovalent vaccine |
| Date/Time Start of Administration | 03/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RV932 |
| Substance Expiration Date | 05/10/2010 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 09/25/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D8043IN8734 |
| Substance Expiration Date | 03/12/2011 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 10/27/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D8043IN8734 |
| Substance Expiration Date | 03/12/2011 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 10/02/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D9334IN9333 |
| Substance Expiration Date | 05/22/2012 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 10/15/2013 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from parents written record |
| Administering Provider | Gina Ricci |
| Substance Lot Number | 8L4B3423 |
| Substance Expiration Date | 07/01/2014 |
| Substance Manufacturer Name | MedImmune, LLC |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | Nasal |
| Administration Site | Bilateral Nares |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Gina Ricci |
| Element | Data |
|---|---|
| Administered Code | influenza, live, intranasal, quadrivalent |
| Date/Time Start of Administration | 07/15/2015 |
| Administered Amount | 0.2 |
| Administered Units | |
| Administration Notes | New immunization record |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 8L4B3521 |
| Substance Expiration Date | 08/15/2015 |
| Substance Manufacturer Name | MedImmune,LLC |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | Nasal |
| Administration Site | Bilateral Nares |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| VIS Publication Date | 08/19/2014 |
| VIS Presentation Date | 07/15/2015 |
| vaccine fund pgm elig cat | Not VFC elig |
| Element | Data |
|---|---|
| Administered Code | influenza, live, intranasal, quadrivalent |
| Date/Time Start of Administration | 11/04/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D9553IN2243 |
| Substance Expiration Date | 04/30/2012 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule |
| Date/Time Start of Administration | 11/23/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RT33 |
| Substance Expiration Date | 01/24/2012 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule |
| Date/Time Start of Administration | 05/23/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RT48 |
| Substance Expiration Date | 09/11/2012 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Code | measles, mumps, rubella, and varicella virus vaccine |
| Date/Time Start of Administration | 10/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | historical |
| Administering Provider | J Martinez |
| Substance Lot Number | 7W27V7491 |
| Substance Expiration Date | 12/15/2010 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Code | measles, mumps, rubella, and varicella virus vaccine |
| Date/Time Start of Administration | 11/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7W87V3452 |
| Substance Expiration Date | 04/13/2013 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Code | measles, mumps, rubella, and varicella virus vaccine |
| Date/Time Start of Administration | 07/15/2015 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | New immunization record |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 7W87V3687 |
| Substance Expiration Date | 07/15/2015 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| VIS Publication Date | 05/21/2010 |
| VIS Presentation Date | 07/15/2015 |
| vaccine fund pgm elig cat | Not VFC elig |
Following the vaccine administration, the patient's mother reports that the patient that evening had persistent, inconsolable crying lasting > 3 hours. |
No Comments |
The vaccinations for the visit have been administered. |
The adverse reaction to the MMRV of persistent, inconsolable crying lasting > 3 hours within 48 hours of dose is recorded in the EMR. |
Identify Adverse Event: The EHR or other clinical software system enables capture of structured data regarding adverse events. |
Verify that vendor can record the adverse reaction of persistent, inconsolable crying lasting > 3 hours within 48 hours of dose correctly and without omission |
No Note |
The adverse reaction to the MMRV of persistent, inconsolable crying lasting > 3 hours within 48 hours of dose is reported to the Immunization Registry using a Z22/VXU message. |
No Comments |
An adverse reaction to the MMRV of persistent, inconsolable crying lasting > 3 hours within 48 hours of dose is recorded in the EMR. |
The adverse reaction has been transmitted to the IIS. |
Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries. |
The VXU/Z22 message passes validation using the NIST Immunization VXU Validation Tool (Z22) (context-free). The content of the message correctly reflects the test data (context-based) in accordance with the Test Data Specification and the Message Content. |
No Note |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| MSH.1 | Field Separator | | | |
| MSH.2 | Encoding Characters | ^~\& | |
| MSH.3 | Sending Application | ||
| MSH.3.1 | Namespace ID | Test EHR Application | |
| MSH.3.2 | Universal ID | ||
| MSH.3.3 | Universal ID Type | ||
| MSH.4 | Sending Facility | ||
| MSH.4.1 | Namespace ID | X68 | |
| MSH.4.2 | Universal ID | ||
| MSH.4.3 | Universal ID Type | ||
| MSH.5 | Receiving Application | ||
| MSH.5.1 | Namespace ID | ||
| MSH.5.2 | Universal ID | ||
| MSH.5.3 | Universal ID Type | ||
| MSH.6 | Receiving Facility | ||
| MSH.6.1 | Namespace ID | NIST Test Iz Reg | |
| MSH.6.2 | Universal ID | ||
| MSH.6.3 | Universal ID Type | ||
| MSH.7 | Date/Time Of Message | ||
| MSH.7.1 | Time | 20120701082240-0500 | |
| MSH.9 | Message Type | ||
| MSH.9.1 | Message Code | VXU | |
| MSH.9.2 | Trigger Event | V04 | |
| MSH.9.3 | Message Structure | VXU_V04 | |
| MSH.10 | Message Control ID | NIST-IZ-001.00 | |
| MSH.11 | Processing ID | ||
| MSH.11.1 | Processing ID | P | |
| MSH.12 | Version ID | ||
| MSH.12.1 | Version ID | 2.5.1 | |
| MSH.15 | Accept Acknowledgment Type | ER | |
| MSH.16 | Application Acknowledgment Type | AL | |
| MSH.21 | Message Profile Identifier | ||
| MSH.21.1 | Entity Identifier | Z22 | |
| MSH.21.2 | Namespace ID | CDCPHINVS | |
| MSH.21.3 | Universal ID | ||
| MSH.21.4 | Universal ID Type | ||
| MSH.22 | Sending Responsible Organization | ||
| MSH.22.1 | Organization Name | ||
| MSH.22.6 | Assigning Authority | ||
| MSH.22.6.1 | Namespace ID | ||
| MSH.22.6.2 | Universal ID | ||
| MSH.22.6.3 | Universal ID Type | ||
| MSH.22.7 | Identifier Type Code | ||
| MSH.22.10 | Organization Identifier | ||
| MSH.23 | Receiving Responsible Organization | ||
| MSH.23.1 | Organization Name | ||
| MSH.23.6 | Assigning Authority | ||
| MSH.23.6.1 | Namespace ID | ||
| MSH.23.6.2 | Universal ID | ||
| MSH.23.6.3 | Universal ID Type | ||
| MSH.23.7 | Identifier Type Code | ||
| MSH.23.10 | Organization Identifier |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| PID.1 | Set ID - PID | 1 | |
| PID.3 | Patient Identifier List | ||
| PID.3.1 | ID Number | 123456 | |
| PID.3.3 | Check Digit Scheme | ||
| PID.3.4 | Assigning Authority | ||
| PID.3.4.1 | Namespace ID | MYEHR | |
| PID.3.4.2 | Universal ID | ||
| PID.3.4.3 | Universal ID Type | ||
| PID.3.5 | Identifier Type Code | MR | |
| PID.3 | Patient Identifier List | ||
| PID.3.1 | ID Number | 987633 | |
| PID.3.3 | Check Digit Scheme | ||
| PID.3.4 | Assigning Authority | ||
| PID.3.4.1 | Namespace ID | MYIIS | |
| PID.3.4.2 | Universal ID | ||
| PID.3.4.3 | Universal ID Type | ||
| PID.3.5 | Identifier Type Code | SR | |
| PID.5 | Patient Name | ||
| PID.5.1 | Family Name | ||
| PID.5.1.1 | Surname | Gonzales | Test Case Fixed |
| PID.5.1.2 | Own Surname Prefix | ||
| PID.5.1.3 | Own Surname | ||
| PID.5.1.4 | Surname Prefix From Partner/Spouse | ||
| PID.5.1.5 | Surname From Partner/Spouse | ||
| PID.5.2 | Given Name | Juana | Test Case Fixed |
| PID.5.3 | Second and Further Given Names or Initials Thereof | Mariana | Test Case Fixed |
| PID.5.7 | Name Type Code | L | Test Case Fixed |
| PID.6 | Mother's Maiden Name | ||
| PID.6.1 | Family Name | ||
| PID.6.1.1 | Surname | Acosta | Test Case Fixed |
| PID.6.1.2 | Own Surname Prefix | ||
| PID.6.1.3 | Own Surname | ||
| PID.6.1.4 | Surname Prefix From Partner/Spouse | ||
| PID.6.1.5 | Surname From Partner/Spouse | ||
| PID.6.7 | Name Type Code | M | Test Case Fixed |
| PID.7 | Date/Time of Birth | ||
| PID.7.1 | Time | 200912231105 | Test Case Fixed |
| PID.8 | Administrative Sex | F | Test Case Fixed |
| PID.10 | Race | ||
| PID.10.1 | Identifier | 2131-1 | Test Case Fixed |
| PID.10.2 | Text | Other Race | Test Case Fixed |
| PID.10.3 | Name of Coding System | HL70005 | Test Case Fixed |
| PID.10.5 | Alternate Text | ||
| PID.10.6 | Name of Alternate Coding System | ||
| PID.11 | Patient Address | ||
| PID.11.1 | Street Address | ||
| PID.11.1.1 | Street or Mailing Address | 4345 Standish Way | Test Case Fixed |
| PID.11.1.2 | Street Name | ||
| PID.11.1.3 | Dwelling Number | ||
| PID.11.2 | Other Designation | ||
| PID.11.3 | City | Stamford | Test Case Fixed |
| PID.11.4 | State or Province | CT | Test Case Fixed |
| PID.11.5 | Zip or Postal Code | 06903 | Test Case Fixed |
| PID.11.6 | Country | USA | Test Case Fixed |
| PID.11.7 | Address Type | L | Test Case Fixed |
| PID.11 | Patient Address | ||
| PID.11.1 | Street Address | ||
| PID.11.1.1 | Street or Mailing Address | 325 Shorline Drive | |
| PID.11.1.2 | Street Name | ||
| PID.11.1.3 | Dwelling Number | ||
| PID.11.2 | Other Designation | ||
| PID.11.3 | City | Stamford | |
| PID.11.4 | State or Province | CT | Test Case Fixed |
| PID.11.5 | Zip or Postal Code | 06901 | |
| PID.11.6 | Country | ||
| PID.11.7 | Address Type | BDL | Test Case Fixed |
| PID.13 | Phone Number - Home | ||
| PID.13.2 | Telecommunication Use Code | PRN | Test Case Fixed |
| PID.13.3 | Telecommunication Equipment Type | PH | Test Case Fixed |
| PID.13.4 | Email Address | ||
| PID.13.6 | Area/City Code | 203 | Test Case Fixed |
| PID.13.7 | Local Number | 5551212 | Test Case Fixed |
| PID.22 | Ethnic Group | ||
| PID.22.1 | Identifier | 2135-2 | Test Case Fixed |
| PID.22.2 | Text | Hispanic or Latino | Test Case Fixed |
| PID.22.3 | Name of Coding System | CDCREC | Test Case Fixed |
| PID.22.5 | Alternate Text | ||
| PID.22.6 | Name of Alternate Coding System | ||
| PID.24 | Multiple Birth Indicator | ||
| PID.25 | Birth Order | ||
| PID.29 | Patient Death Date and Time | ||
| PID.29.1 | Time | ||
| PID.30 | Patient Death Indicator |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| PD1.11 | Publicity Code | ||
| PD1.11.1 | Identifier | 02 | |
| PD1.11.2 | Text | Reminder/Recall - any method | |
| PD1.11.3 | Name of Coding System | HL70215 | |
| PD1.11.5 | Alternate Text | ||
| PD1.11.6 | Name of Alternate Coding System | ||
| PD1.12 | Protection Indicator | ||
| PD1.13 | Protection Indicator Effective Date | ||
| PD1.16 | Immunization Registry Status | A | |
| PD1.17 | Immunization Registry Status Effective Date | 20120701 | |
| PD1.18 | Publicity Code Effective Date | 20120701 |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| NK1.1 | Set ID - NK1 | 1 | |
| NK1.2 | Name | ||
| NK1.2.1 | Family Name | ||
| NK1.2.1.1 | Surname | Gonzales | |
| NK1.2.1.2 | Own Surname Prefix | ||
| NK1.2.1.3 | Own Surname | ||
| NK1.2.1.4 | Surname Prefix From Partner/Spouse | ||
| NK1.2.1.5 | Surname From Partner/Spouse | ||
| NK1.2.2 | Given Name | Joanna | Test Case Fixed |
| NK1.2.3 | Second and Further Given Names or Initials Thereof | Merida | Test Case Fixed |
| NK1.2.7 | Name Type Code | L | Test Case Fixed |
| NK1.3 | Relationship | ||
| NK1.3.1 | Identifier | GRP | Test Case Fixed |
| NK1.3.2 | Text | Grandparent | Test Case Fixed |
| NK1.3.3 | Name of Coding System | HL70063 | Test Case Fixed |
| NK1.3.5 | Alternate Text | ||
| NK1.3.6 | Name of Alternate Coding System | ||
| NK1.4 | Address | ||
| NK1.4.1 | Street Address | ||
| NK1.4.1.1 | Street or Mailing Address | 4345 Standish Way | Test Case Fixed |
| NK1.4.1.2 | Street Name | ||
| NK1.4.1.3 | Dwelling Number | ||
| NK1.4.2 | Other Designation | ||
| NK1.4.3 | City | Stamford | Test Case Fixed |
| NK1.4.4 | State or Province | CT | Test Case Fixed |
| NK1.4.5 | Zip or Postal Code | 06901 | Test Case Fixed |
| NK1.4.6 | Country | ||
| NK1.4.7 | Address Type | L | Test Case Fixed |
| NK1.5 | Phone Number | ||
| NK1.5.2 | Telecommunication Use Code | PRN | Test Case Fixed |
| NK1.5.3 | Telecommunication Equipment Type | PH | Test Case Fixed |
| NK1.5.4 | Email Address | ||
| NK1.5.6 | Area/City Code | 203 | Test Case Fixed |
| NK1.5.7 | Local Number | 5551212 | Test Case Fixed |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Sirtis | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | Lisa | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Carter | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Jane | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | SH | |
| ORC.17.2 | Text | Shoreline Hospital | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Molina | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | Sandra | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Smith | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Frank | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | SP | |
| ORC.17.2 | Text | Shoreline Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Herrera | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Carlos | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Herrera | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Carlos | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Herrera | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Carlos | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Herrera | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Carlos | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | Test Case Fixed |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Herrera | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Carlos | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Molina | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | Sandra | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | SP | |
| ORC.17.2 | Text | Shoreline Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Herrera | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Carlos | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Herrera | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Carlos | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Herrera | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Carlos | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Herrera | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Carlos | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Herrera | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Carlos | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Herrera | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Carlos | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Molina | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | Sandra | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | SP | |
| ORC.17.2 | Text | Shoreline Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 9999 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Molina | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | Sandra | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Smith | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Frank | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | SP | |
| ORC.17.2 | Text | Shoreline Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Herrera | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Carlos | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Herrera | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Carlos | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Herrera | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Carlos | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Herrera | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Carlos | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Herrera | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Carlos | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Herrera | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Carlos | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Herrera | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Carlos | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Herrera | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Carlos | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Herrera | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Carlos | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Molina | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | Sandra | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Ricci | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Gina | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | SP | |
| ORC.17.2 | Text | Shoreline Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Molina | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | Sandra | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Smith | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Frank | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | SP | |
| ORC.17.2 | Text | Shoreline Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Herrera | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Carlos | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Herrera | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Carlos | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Smith | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | F | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Smith | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | F | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Smith | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | F | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Molina | Test Case Fixed |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | Sandra | Test Case Fixed |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Smith | Test Case Fixed |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Frank | Test Case Fixed |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | Test Case Fixed |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | SP | |
| ORC.17.2 | Text | Shoreline Pediatrics | Test Case Fixed |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20091123 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 08 | |
| RXA.5.2 | Text | hepatitis B vaccine, pediatric or pediatric/adolescent dosage | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | ENGERIX-B | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Sirtis | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | Lisa | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 6332FK33 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20101214 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | SKB | |
| RXA.17.2 | Text | GlaxoSmithKline Biologicals SA | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20100115 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 45 | |
| RXA.5.2 | Text | hepatitis B vaccine, unspecified formulation | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | ENGERIX-B | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 01 | |
| RXA.9.2 | Text | Historical Immunization | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Molina | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | Sandra | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 6352FK1 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20101001 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | SKB | |
| RXA.17.2 | Text | GlaxoSmithKline Biologicals SA | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20101030 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 08 | |
| RXA.5.2 | Text | hepatitis B vaccine, pediatric or pediatric/adolescent dosage | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | ENGERIX-B | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 6352FK24 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20120831 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | SKB | |
| RXA.17.2 | Text | GlaxoSmithKline Biologicals SA | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20100122 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 107 | |
| RXA.5.2 | Text | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | DAPTACEL | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D409QS2341 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20111130 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | Sanofi Pasteur Inc | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20100323 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 106 | |
| RXA.5.2 | Text | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | DAPTACEL | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D409QS2433 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20110904 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | Sanofi Pasteur Inc | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20100522 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 106 | |
| RXA.5.2 | Text | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | DAPTACEL | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D409QS3255 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20101201 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | Sanofi Pasteur Inc | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20110221 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 106 | |
| RXA.5.2 | Text | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | DAPTACEL | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D409QS249 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20110301 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | Sanofi Pasteur Inc | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20140831 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 106 | |
| RXA.5.2 | Text | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | DAPTACEL | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 02 | |
| RXA.9.2 | Text | Historical information - from other provider | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Casera | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | Linda | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D643QS8243 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20140901 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | Sanofi Pasteur Inc | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20100122 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 49 | |
| RXA.5.2 | Text | Haemophilus influenzae type b vaccine, PRP-OMP conjugate | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | PedvaxHIB | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 7M54K9245 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20100324 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | MSD | |
| RXA.17.2 | Text | Merck Sharp \T\ Dohme Corp | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20100323 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 49 | |
| RXA.5.2 | Text | Haemophilus influenzae type b vaccine, PRP-OMP conjugate | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | PedvaxHIB | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 7M55K3342 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20101030 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | MSD | |
| RXA.17.2 | Text | Merck Sharp \T\ Dohme Corp | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20100522 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 49 | |
| RXA.5.2 | Text | Haemophilus influenzae type b vaccine, PRP-OMP conjugate | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | PedvaxHIB | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 7M75K4566 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20100523 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | MSD | |
| RXA.17.2 | Text | Merck Sharp \T\ Dohme Corp | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20110221 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 49 | |
| RXA.5.2 | Text | Haemophilus influenzae type b vaccine, PRP-OMP conjugate | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | PedvaxHIB | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 7M53K5534 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20110222 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | MSD | |
| RXA.17.2 | Text | Merck Sharp \T\ Dohme Corp | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20100122 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 10 | |
| RXA.5.2 | Text | poliovirus vaccine, inactivated | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | IPOL | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D333PV2431 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20101004 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | Sanofi Pasteur Inc | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20100323 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 10 | |
| RXA.5.2 | Text | poliovirus vaccine, inactivated | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | IPOL | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D333PV4344 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20100323 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | Sanofi Pasteur Inc | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20110221 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 10 | |
| RXA.5.2 | Text | poliovirus vaccine, inactivated | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | IPOL | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 02 | |
| RXA.9.2 | Text | Historical information - from other provider | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Casera | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | Linda | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D335PV9644 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20110222 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | Sanofi Pasteur Inc | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20150519 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 10 | |
| RXA.5.2 | Text | poliovirus vaccine, inactivated | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | ||
| RXA.5.6 | Name of Alternate Coding System | ||
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | ||
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | ||
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | ||
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | ||
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | ||
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | ||
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | ||
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | ||
| RXA.17.2 | Text | ||
| RXA.17.3 | Name of Coding System | ||
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | 00 | |
| RXA.18.2 | Text | Parental decision | |
| RXA.18.3 | Name of Coding System | NIP002 | |
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | RE | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20100121 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 133 | |
| RXA.5.2 | Text | pneumococcal conjugate vaccine, 13 valent | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | PREVNAR 13 | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | P243V3281 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20100130 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PFR | |
| RXA.17.2 | Text | Pfizer, Inc | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20100323 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 133 | |
| RXA.5.2 | Text | pneumococcal conjugate vaccine, 13 valent | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | PREVNAR 13 | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | P343V8321 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20100330 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PFR | |
| RXA.17.2 | Text | Pfizer, Inc | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20100522 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 133 | |
| RXA.5.2 | Text | pneumococcal conjugate vaccine, 13 valent | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | PREVNAR 13 | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | P853V2164 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20100830 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PFR | |
| RXA.17.2 | Text | Pfizer, Inc | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20110221 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 133 | |
| RXA.5.2 | Text | pneumococcal conjugate vaccine, 13 valent | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | PREVNAR 13 | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | P853V58532 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20110418 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PFR | |
| RXA.17.2 | Text | Pfizer, Inc | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20100122 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 119 | |
| RXA.5.2 | Text | rotavirus, live, monovalent vaccine | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | ROTARIX | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 6359RV533 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20100215 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | SKB | |
| RXA.17.2 | Text | GlaxoSmithKline Biologicals SA | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20100323 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 119 | |
| RXA.5.2 | Text | rotavirus, live, monovalent vaccine | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | ROTARIX | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 6359RV932 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20100510 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | SKB | |
| RXA.17.2 | Text | GlaxoSmithKline Biologicals SA | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20100925 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 161 | |
| RXA.5.2 | Text | Influenza, injectable,quadrivalent, preservative free, pediatric | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | FLUZONE QUADRIVALENT | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D8043IN8734 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20110312 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | Sanofi PasteurGlaxoSmithKline Biologicals SA | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20101027 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 161 | |
| RXA.5.2 | Text | Influenza, injectable,quadrivalent, preservative free, pediatric | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | FLUZONE QUADRIVALENT | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D8043IN8734 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20110312 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | Sanofi PasteurGlaxoSmithKline Biologicals SA | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20111002 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 161 | |
| RXA.5.2 | Text | Influenza, injectable,quadrivalent, preservative free, pediatric | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | FLUZONE QUADRIVALENT | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D9334IN9333 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20120522 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | Sanofi PasteurGlaxoSmithKline Biologicals SA | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20131015 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 161 | |
| RXA.5.2 | Text | Influenza, injectable,quadrivalent, preservative free, pediatric | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | FLUZONE QUADRIVALENT | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 03 | |
| RXA.9.2 | Text | Historical information - from parents written record | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Ricci | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | Gina | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 8L4B3423 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20140701 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | MED | |
| RXA.17.2 | Text | MedImmune, LLC | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20150715 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 149 | |
| RXA.5.2 | Text | influenza, live, intranasal, quadrivalent | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | FluMist Quadrivalent | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 0.2 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | mL | |
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | UCUM | |
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 00 | |
| RXA.9.2 | Text | New immunization record | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Molina | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | Sandra | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 8L4B3521 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20150815 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | MED | |
| RXA.17.2 | Text | MedImmune,LLC | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20121104 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 149 | |
| RXA.5.2 | Text | influenza, live, intranasal, quadrivalent | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | FluMist Quadrivalent | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D9553IN2243 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20120430 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | Sanofi PasteurGlaxoSmithKline Biologicals SA | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20111123 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 83 | |
| RXA.5.2 | Text | hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | HAVRIX | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 6359RT33 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20120124 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | SKB | |
| RXA.17.2 | Text | GlaxoSmithKline Biologicals SA | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20120523 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 83 | |
| RXA.5.2 | Text | hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | HAVRIX | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 6359RT48 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20120911 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | Sanofi PasteurGlaxoSmithKline Biologicals SA | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20101023 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 94 | |
| RXA.5.2 | Text | measles, mumps, rubella, and varicella virus vaccine | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | ProQuad | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 01 | |
| RXA.9.2 | Text | historical | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 7W27V7491 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20101215 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | MSD | |
| RXA.17.2 | Text | Merck Sharp \T\ Dohme Corp | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20121122 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 94 | |
| RXA.5.2 | Text | measles, mumps, rubella, and varicella virus vaccine | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | ProQuad | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 7W87V3452 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20130413 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | MSD | |
| RXA.17.2 | Text | Merck Sharp \T\ Dohme Corp | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20150715 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 94 | Test Case Fixed |
| RXA.5.2 | Text | measles, mumps, rubella, and varicella virus vaccine | Test Case Fixed |
| RXA.5.3 | Name of Coding System | CVX | Test Case Fixed |
| RXA.5.5 | Alternate Text | ProQuad | Test Case Fixed |
| RXA.5.6 | Name of Alternate Coding System | NDC | Test Case Fixed |
| RXA.6 | Administered Amount | 0.5 | Test Case Fixed |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | mL | Test Case Fixed |
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | UCUM | Test Case Fixed |
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 00 | Test Case Fixed |
| RXA.9.2 | Text | New immunization record | Test Case Fixed |
| RXA.9.3 | Name of Coding System | NIP001 | Test Case Fixed |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Molina | Test Case Fixed |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | Sandra | Test Case Fixed |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 7W87V3687 | Test Case Fixed |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20150715 | Test Case Fixed |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | MSD | Test Case Fixed |
| RXA.17.2 | Text | Merck Sharp \T\ Dohme Corp | Test Case Fixed |
| RXA.17.3 | Name of Coding System | MVX | Test Case Fixed |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | Test Case Fixed |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LT | |
| RXR.2.2 | Text | Left Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | RT | |
| RXR.2.2 | Text | Right Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LT | |
| RXR.2.2 | Text | Left Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LT | |
| RXR.2.2 | Text | Left Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | RT | |
| RXR.2.2 | Text | Right Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LT | |
| RXR.2.2 | Text | Left Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | RT | |
| RXR.2.2 | Text | Right Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LT | |
| RXR.2.2 | Text | Left Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | RT | |
| RXR.2.2 | Text | Right Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C38299 | |
| RXR.1.2 | Text | SC | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | Subcutaneous | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C38299 | |
| RXR.1.2 | Text | SC | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | Subcutaneous | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C38299 | |
| RXR.1.2 | Text | SC | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | Subcutaneous | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LT | |
| RXR.2.2 | Text | Left Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C38299 | |
| RXR.1.2 | Text | SC | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | Subcutaneous | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LT | |
| RXR.2.2 | Text | Left Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | RT | |
| RXR.2.2 | Text | Right Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LT | |
| RXR.2.2 | Text | Left Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | RT | |
| RXR.2.2 | Text | Right Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LT | |
| RXR.2.2 | Text | Left Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | RT | |
| RXR.2.2 | Text | Right Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C38284 | |
| RXR.1.2 | Text | Nasal | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | Nasal | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | BN | |
| RXR.2.2 | Text | Bilateral Nares | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C38284 | |
| RXR.1.2 | Text | Nasal | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | Nasal | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | BN | |
| RXR.2.2 | Text | Bilateral Nares | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | RD | |
| RXR.2.2 | Text | Right Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C38299 | |
| RXR.1.2 | Text | Subcutaneous | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | Subcutaneous | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C38299 | |
| RXR.1.2 | Text | Subcutaneous | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | Subcutaneous | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C38299 | Test Case Fixed |
| RXR.1.2 | Text | Subcutaneous | Test Case Fixed |
| RXR.1.3 | Name of Coding System | NCIT | Test Case Fixed |
| RXR.1.5 | Alternate Text | Subcutaneous | Test Case Fixed |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | Test Case Fixed |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | Test Case Fixed |
| RXR.2.2 | Text | Left Deltoid | Test Case Fixed |
| RXR.2.3 | Name of Coding System | HL70163 | Test Case Fixed |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 21 | |
| OBX.2 | Value Type | CE | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 31044-1 | |
| OBX.3.2 | Text | Reaction | |
| OBX.3.3 | Name of Coding System | LN | |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20100522 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 2 | |
| OBX.2 | Value Type | TS | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 29768-9 | |
| OBX.3.2 | Text | VIS Publication Date | |
| OBX.3.3 | Name of Coding System | LN | |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.5.1 | Time | 20140819 | |
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 3 | |
| OBX.2 | Value Type | TS | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 29769-7 | |
| OBX.3.2 | Text | VIS Presentation Date | |
| OBX.3.3 | Name of Coding System | LN | |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.5.1 | Time | 20150715 | |
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 1 | |
| OBX.2 | Value Type | CE | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 64994-7 | |
| OBX.3.2 | Text | vaccine fund pgm elig cat | |
| OBX.3.3 | Name of Coding System | LN | |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 2 | |
| OBX.2 | Value Type | TS | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 29768-9 | |
| OBX.3.2 | Text | VIS Publication Date | |
| OBX.3.3 | Name of Coding System | LN | |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.5.1 | Time | 20100521 | |
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 3 | |
| OBX.2 | Value Type | TS | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 29769-7 | |
| OBX.3.2 | Text | VIS Presentation Date | |
| OBX.3.3 | Name of Coding System | LN | |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.5.1 | Time | 20150715 | |
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 1 | |
| OBX.2 | Value Type | CE | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 64994-7 | |
| OBX.3.2 | Text | vaccine fund pgm elig cat | |
| OBX.3.3 | Name of Coding System | LN | |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 1 | |
| OBX.2 | Value Type | CE | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 64994-7 | |
| OBX.3.2 | Text | vaccine fund pgm elig cat | |
| OBX.3.3 | Name of Coding System | LN | |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 21 | |
| OBX.2 | Value Type | CE | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 31044-1 | Test Case Fixed |
| OBX.3.2 | Text | Reaction | Test Case Fixed |
| OBX.3.3 | Name of Coding System | LN | Test Case Fixed |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| MSH.1 | Field Separator | | | |
| MSH.2 | Encoding Characters | ^~\& | |
| MSH.3 | Sending Application | ||
| MSH.3.1 | Namespace ID | Test EHR Application | |
| MSH.3.2 | Universal ID | ||
| MSH.3.3 | Universal ID Type | ||
| MSH.4 | Sending Facility | ||
| MSH.4.1 | Namespace ID | X68 | |
| MSH.4.2 | Universal ID | ||
| MSH.4.3 | Universal ID Type | ||
| MSH.5 | Receiving Application | ||
| MSH.5.1 | Namespace ID | ||
| MSH.5.2 | Universal ID | ||
| MSH.5.3 | Universal ID Type | ||
| MSH.6 | Receiving Facility | ||
| MSH.6.1 | Namespace ID | NIST Test Iz Reg | |
| MSH.6.2 | Universal ID | ||
| MSH.6.3 | Universal ID Type | ||
| MSH.7 | Date/Time Of Message | ||
| MSH.7.1 | Time | 20120701082240-0500 | |
| MSH.9 | Message Type | ||
| MSH.9.1 | Message Code | VXU | |
| MSH.9.2 | Trigger Event | V04 | |
| MSH.9.3 | Message Structure | VXU_V04 | |
| MSH.10 | Message Control ID | NIST-IZ-001.00 | |
| MSH.11 | Processing ID | ||
| MSH.11.1 | Processing ID | P | |
| MSH.12 | Version ID | ||
| MSH.12.1 | Version ID | 2.5.1 | |
| MSH.15 | Accept Acknowledgment Type | ER | |
| MSH.16 | Application Acknowledgment Type | AL | |
| MSH.21 | Message Profile Identifier | ||
| MSH.21.1 | Entity Identifier | Z22 | |
| MSH.21.2 | Namespace ID | CDCPHINVS | |
| MSH.21.3 | Universal ID | ||
| MSH.21.4 | Universal ID Type | ||
| MSH.22 | Sending Responsible Organization | ||
| MSH.22.1 | Organization Name | ||
| MSH.22.6 | Assigning Authority | ||
| MSH.22.6.1 | Namespace ID | ||
| MSH.22.6.2 | Universal ID | ||
| MSH.22.6.3 | Universal ID Type | ||
| MSH.22.7 | Identifier Type Code | ||
| MSH.22.10 | Organization Identifier | ||
| MSH.23 | Receiving Responsible Organization | ||
| MSH.23.1 | Organization Name | ||
| MSH.23.6 | Assigning Authority | ||
| MSH.23.6.1 | Namespace ID | ||
| MSH.23.6.2 | Universal ID | ||
| MSH.23.6.3 | Universal ID Type | ||
| MSH.23.7 | Identifier Type Code | ||
| MSH.23.10 | Organization Identifier |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| PID.1 | Set ID - PID | 1 | |
| PID.3 | Patient Identifier List | ||
| PID.3.1 | ID Number | 123456 | |
| PID.3.3 | Check Digit Scheme | ||
| PID.3.4 | Assigning Authority | ||
| PID.3.4.1 | Namespace ID | MYEHR | |
| PID.3.4.2 | Universal ID | ||
| PID.3.4.3 | Universal ID Type | ||
| PID.3.5 | Identifier Type Code | MR | |
| PID.3 | Patient Identifier List | ||
| PID.3.1 | ID Number | 987633 | |
| PID.3.3 | Check Digit Scheme | ||
| PID.3.4 | Assigning Authority | ||
| PID.3.4.1 | Namespace ID | MYIIS | |
| PID.3.4.2 | Universal ID | ||
| PID.3.4.3 | Universal ID Type | ||
| PID.3.5 | Identifier Type Code | SR | |
| PID.5 | Patient Name | ||
| PID.5.1 | Family Name | ||
| PID.5.1.1 | Surname | Gonzales | Test Case Fixed |
| PID.5.1.2 | Own Surname Prefix | ||
| PID.5.1.3 | Own Surname | ||
| PID.5.1.4 | Surname Prefix From Partner/Spouse | ||
| PID.5.1.5 | Surname From Partner/Spouse | ||
| PID.5.2 | Given Name | Juana | Test Case Fixed |
| PID.5.3 | Second and Further Given Names or Initials Thereof | Mariana | Test Case Fixed |
| PID.5.7 | Name Type Code | L | Test Case Fixed |
| PID.6 | Mother's Maiden Name | ||
| PID.6.1 | Family Name | ||
| PID.6.1.1 | Surname | Acosta | Test Case Fixed |
| PID.6.1.2 | Own Surname Prefix | ||
| PID.6.1.3 | Own Surname | ||
| PID.6.1.4 | Surname Prefix From Partner/Spouse | ||
| PID.6.1.5 | Surname From Partner/Spouse | ||
| PID.6.7 | Name Type Code | M | Test Case Fixed |
| PID.7 | Date/Time of Birth | ||
| PID.7.1 | Time | 200912231105 | Test Case Fixed |
| PID.8 | Administrative Sex | F | Test Case Fixed |
| PID.10 | Race | ||
| PID.10.1 | Identifier | 2131-1 | Test Case Fixed |
| PID.10.2 | Text | Other Race | Test Case Fixed |
| PID.10.3 | Name of Coding System | HL70005 | Test Case Fixed |
| PID.10.5 | Alternate Text | ||
| PID.10.6 | Name of Alternate Coding System | ||
| PID.11 | Patient Address | ||
| PID.11.1 | Street Address | ||
| PID.11.1.1 | Street or Mailing Address | 4345 Standish Way | Test Case Fixed |
| PID.11.1.2 | Street Name | ||
| PID.11.1.3 | Dwelling Number | ||
| PID.11.2 | Other Designation | ||
| PID.11.3 | City | Stamford | Test Case Fixed |
| PID.11.4 | State or Province | CT | Test Case Fixed |
| PID.11.5 | Zip or Postal Code | 06903 | Test Case Fixed |
| PID.11.6 | Country | USA | Test Case Fixed |
| PID.11.7 | Address Type | L | Test Case Fixed |
| PID.11 | Patient Address | ||
| PID.11.1 | Street Address | ||
| PID.11.1.1 | Street or Mailing Address | 325 Shorline Drive | |
| PID.11.1.2 | Street Name | ||
| PID.11.1.3 | Dwelling Number | ||
| PID.11.2 | Other Designation | ||
| PID.11.3 | City | Stamford | |
| PID.11.4 | State or Province | CT | Test Case Fixed |
| PID.11.5 | Zip or Postal Code | 06901 | |
| PID.11.6 | Country | ||
| PID.11.7 | Address Type | BDL | Test Case Fixed |
| PID.13 | Phone Number - Home | ||
| PID.13.2 | Telecommunication Use Code | PRN | Test Case Fixed |
| PID.13.3 | Telecommunication Equipment Type | PH | Test Case Fixed |
| PID.13.4 | Email Address | ||
| PID.13.6 | Area/City Code | 203 | Test Case Fixed |
| PID.13.7 | Local Number | 5551212 | Test Case Fixed |
| PID.22 | Ethnic Group | ||
| PID.22.1 | Identifier | 2135-2 | Test Case Fixed |
| PID.22.2 | Text | Hispanic or Latino | Test Case Fixed |
| PID.22.3 | Name of Coding System | CDCREC | Test Case Fixed |
| PID.22.5 | Alternate Text | ||
| PID.22.6 | Name of Alternate Coding System | ||
| PID.24 | Multiple Birth Indicator | ||
| PID.25 | Birth Order | ||
| PID.29 | Patient Death Date and Time | ||
| PID.29.1 | Time | ||
| PID.30 | Patient Death Indicator |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| PD1.11 | Publicity Code | ||
| PD1.11.1 | Identifier | 02 | |
| PD1.11.2 | Text | Reminder/Recall - any method | |
| PD1.11.3 | Name of Coding System | HL70215 | |
| PD1.11.5 | Alternate Text | ||
| PD1.11.6 | Name of Alternate Coding System | ||
| PD1.12 | Protection Indicator | ||
| PD1.13 | Protection Indicator Effective Date | ||
| PD1.16 | Immunization Registry Status | A | |
| PD1.17 | Immunization Registry Status Effective Date | 20120701 | |
| PD1.18 | Publicity Code Effective Date | 20120701 |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| NK1.1 | Set ID - NK1 | 1 | |
| NK1.2 | Name | ||
| NK1.2.1 | Family Name | ||
| NK1.2.1.1 | Surname | Gonzales | |
| NK1.2.1.2 | Own Surname Prefix | ||
| NK1.2.1.3 | Own Surname | ||
| NK1.2.1.4 | Surname Prefix From Partner/Spouse | ||
| NK1.2.1.5 | Surname From Partner/Spouse | ||
| NK1.2.2 | Given Name | Joanna | Test Case Fixed |
| NK1.2.3 | Second and Further Given Names or Initials Thereof | Merida | Test Case Fixed |
| NK1.2.7 | Name Type Code | L | Test Case Fixed |
| NK1.3 | Relationship | ||
| NK1.3.1 | Identifier | GRP | Test Case Fixed |
| NK1.3.2 | Text | Grandparent | Test Case Fixed |
| NK1.3.3 | Name of Coding System | HL70063 | Test Case Fixed |
| NK1.3.5 | Alternate Text | ||
| NK1.3.6 | Name of Alternate Coding System | ||
| NK1.4 | Address | ||
| NK1.4.1 | Street Address | ||
| NK1.4.1.1 | Street or Mailing Address | 4345 Standish Way | Test Case Fixed |
| NK1.4.1.2 | Street Name | ||
| NK1.4.1.3 | Dwelling Number | ||
| NK1.4.2 | Other Designation | ||
| NK1.4.3 | City | Stamford | Test Case Fixed |
| NK1.4.4 | State or Province | CT | Test Case Fixed |
| NK1.4.5 | Zip or Postal Code | 06901 | Test Case Fixed |
| NK1.4.6 | Country | ||
| NK1.4.7 | Address Type | L | Test Case Fixed |
| NK1.5 | Phone Number | ||
| NK1.5.2 | Telecommunication Use Code | PRN | Test Case Fixed |
| NK1.5.3 | Telecommunication Equipment Type | PH | Test Case Fixed |
| NK1.5.4 | Email Address | ||
| NK1.5.6 | Area/City Code | 203 | Test Case Fixed |
| NK1.5.7 | Local Number | 5551212 | Test Case Fixed |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Sirtis | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | Lisa | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Carter | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Jane | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | SH | |
| ORC.17.2 | Text | Shoreline Hospital | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Molina | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | Sandra | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Smith | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Frank | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | SP | |
| ORC.17.2 | Text | Shoreline Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Herrera | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Carlos | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Herrera | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Carlos | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Herrera | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Carlos | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Herrera | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Carlos | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | Test Case Fixed |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Herrera | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Carlos | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Molina | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | Sandra | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | SP | |
| ORC.17.2 | Text | Shoreline Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Herrera | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Carlos | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Herrera | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Carlos | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Herrera | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Carlos | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Herrera | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Carlos | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Herrera | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Carlos | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Herrera | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Carlos | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Molina | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | Sandra | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | SP | |
| ORC.17.2 | Text | Shoreline Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 9999 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Molina | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | Sandra | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Smith | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Frank | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | SP | |
| ORC.17.2 | Text | Shoreline Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Herrera | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Carlos | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Herrera | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Carlos | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Herrera | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Carlos | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Herrera | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Carlos | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Herrera | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Carlos | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Herrera | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Carlos | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Herrera | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Carlos | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Herrera | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Carlos | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Herrera | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Carlos | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Molina | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | Sandra | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Ricci | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Gina | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | SP | |
| ORC.17.2 | Text | Shoreline Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Molina | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | Sandra | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Smith | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Frank | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | SP | |
| ORC.17.2 | Text | Shoreline Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Herrera | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Carlos | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Herrera | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Carlos | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Smith | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | F | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Smith | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | F | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Smith | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | F | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Molina | Test Case Fixed |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | Sandra | Test Case Fixed |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Smith | Test Case Fixed |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Frank | Test Case Fixed |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | Test Case Fixed |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | SP | |
| ORC.17.2 | Text | Shoreline Pediatrics | Test Case Fixed |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20091123 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 08 | |
| RXA.5.2 | Text | hepatitis B vaccine, pediatric or pediatric/adolescent dosage | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | ENGERIX-B | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Sirtis | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | Lisa | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 6332FK33 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20101214 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | SKB | |
| RXA.17.2 | Text | GlaxoSmithKline Biologicals SA | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20100115 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 45 | |
| RXA.5.2 | Text | hepatitis B vaccine, unspecified formulation | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | ENGERIX-B | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 01 | |
| RXA.9.2 | Text | Historical Immunization | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Molina | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | Sandra | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 6352FK1 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20101001 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | SKB | |
| RXA.17.2 | Text | GlaxoSmithKline Biologicals SA | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20101030 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 08 | |
| RXA.5.2 | Text | hepatitis B vaccine, pediatric or pediatric/adolescent dosage | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | ENGERIX-B | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 6352FK24 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20120831 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | SKB | |
| RXA.17.2 | Text | GlaxoSmithKline Biologicals SA | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20100122 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 107 | |
| RXA.5.2 | Text | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | DAPTACEL | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D409QS2341 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20111130 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | Sanofi Pasteur Inc | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20100323 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 106 | |
| RXA.5.2 | Text | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | DAPTACEL | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D409QS2433 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20110904 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | Sanofi Pasteur Inc | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20100522 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 106 | |
| RXA.5.2 | Text | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | DAPTACEL | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D409QS3255 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20101201 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | Sanofi Pasteur Inc | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20110221 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 106 | |
| RXA.5.2 | Text | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | DAPTACEL | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D409QS249 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20110301 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | Sanofi Pasteur Inc | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20140831 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 106 | |
| RXA.5.2 | Text | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | DAPTACEL | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 02 | |
| RXA.9.2 | Text | Historical information - from other provider | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Casera | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | Linda | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D643QS8243 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20140901 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | Sanofi Pasteur Inc | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20100122 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 49 | |
| RXA.5.2 | Text | Haemophilus influenzae type b vaccine, PRP-OMP conjugate | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | PedvaxHIB | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 7M54K9245 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20100324 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | MSD | |
| RXA.17.2 | Text | Merck Sharp \T\ Dohme Corp | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20100323 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 49 | |
| RXA.5.2 | Text | Haemophilus influenzae type b vaccine, PRP-OMP conjugate | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | PedvaxHIB | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 7M55K3342 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20101030 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | MSD | |
| RXA.17.2 | Text | Merck Sharp \T\ Dohme Corp | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20100522 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 49 | |
| RXA.5.2 | Text | Haemophilus influenzae type b vaccine, PRP-OMP conjugate | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | PedvaxHIB | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 7M75K4566 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20100523 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | MSD | |
| RXA.17.2 | Text | Merck Sharp \T\ Dohme Corp | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20110221 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 49 | |
| RXA.5.2 | Text | Haemophilus influenzae type b vaccine, PRP-OMP conjugate | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | PedvaxHIB | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 7M53K5534 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20110222 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | MSD | |
| RXA.17.2 | Text | Merck Sharp \T\ Dohme Corp | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20100122 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 10 | |
| RXA.5.2 | Text | poliovirus vaccine, inactivated | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | IPOL | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D333PV2431 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20101004 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | Sanofi Pasteur Inc | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20100323 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 10 | |
| RXA.5.2 | Text | poliovirus vaccine, inactivated | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | IPOL | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D333PV4344 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20100323 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | Sanofi Pasteur Inc | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20110221 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 10 | |
| RXA.5.2 | Text | poliovirus vaccine, inactivated | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | IPOL | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 02 | |
| RXA.9.2 | Text | Historical information - from other provider | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Casera | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | Linda | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D335PV9644 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20110222 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | Sanofi Pasteur Inc | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20150519 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 10 | |
| RXA.5.2 | Text | poliovirus vaccine, inactivated | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | ||
| RXA.5.6 | Name of Alternate Coding System | ||
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | ||
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | ||
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | ||
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | ||
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | ||
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | ||
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | ||
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | ||
| RXA.17.2 | Text | ||
| RXA.17.3 | Name of Coding System | ||
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | 00 | |
| RXA.18.2 | Text | Parental decision | |
| RXA.18.3 | Name of Coding System | NIP002 | |
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | RE | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20100121 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 133 | |
| RXA.5.2 | Text | pneumococcal conjugate vaccine, 13 valent | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | PREVNAR 13 | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | P243V3281 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20100130 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PFR | |
| RXA.17.2 | Text | Pfizer, Inc | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20100323 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 133 | |
| RXA.5.2 | Text | pneumococcal conjugate vaccine, 13 valent | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | PREVNAR 13 | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | P343V8321 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20100330 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PFR | |
| RXA.17.2 | Text | Pfizer, Inc | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20100522 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 133 | |
| RXA.5.2 | Text | pneumococcal conjugate vaccine, 13 valent | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | PREVNAR 13 | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | P853V2164 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20100830 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PFR | |
| RXA.17.2 | Text | Pfizer, Inc | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20110221 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 133 | |
| RXA.5.2 | Text | pneumococcal conjugate vaccine, 13 valent | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | PREVNAR 13 | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | P853V58532 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20110418 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PFR | |
| RXA.17.2 | Text | Pfizer, Inc | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20100122 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 119 | |
| RXA.5.2 | Text | rotavirus, live, monovalent vaccine | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | ROTARIX | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 6359RV533 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20100215 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | SKB | |
| RXA.17.2 | Text | GlaxoSmithKline Biologicals SA | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20100323 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 119 | |
| RXA.5.2 | Text | rotavirus, live, monovalent vaccine | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | ROTARIX | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 6359RV932 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20100510 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | SKB | |
| RXA.17.2 | Text | GlaxoSmithKline Biologicals SA | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20100925 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 161 | |
| RXA.5.2 | Text | Influenza, injectable,quadrivalent, preservative free, pediatric | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | FLUZONE QUADRIVALENT | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D8043IN8734 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20110312 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | Sanofi PasteurGlaxoSmithKline Biologicals SA | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20101027 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 161 | |
| RXA.5.2 | Text | Influenza, injectable,quadrivalent, preservative free, pediatric | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | FLUZONE QUADRIVALENT | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D8043IN8734 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20110312 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | Sanofi PasteurGlaxoSmithKline Biologicals SA | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20111002 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 161 | |
| RXA.5.2 | Text | Influenza, injectable,quadrivalent, preservative free, pediatric | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | FLUZONE QUADRIVALENT | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D9334IN9333 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20120522 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | Sanofi PasteurGlaxoSmithKline Biologicals SA | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20131015 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 161 | |
| RXA.5.2 | Text | Influenza, injectable,quadrivalent, preservative free, pediatric | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | FLUZONE QUADRIVALENT | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 03 | |
| RXA.9.2 | Text | Historical information - from parents written record | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Ricci | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | Gina | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 8L4B3423 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20140701 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | MED | |
| RXA.17.2 | Text | MedImmune, LLC | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20150715 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 149 | |
| RXA.5.2 | Text | influenza, live, intranasal, quadrivalent | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | FluMist Quadrivalent | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 0.2 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | mL | |
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | UCUM | |
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 00 | |
| RXA.9.2 | Text | New immunization record | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Molina | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | Sandra | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 8L4B3521 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20150815 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | MED | |
| RXA.17.2 | Text | MedImmune,LLC | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20121104 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 149 | |
| RXA.5.2 | Text | influenza, live, intranasal, quadrivalent | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | FluMist Quadrivalent | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D9553IN2243 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20120430 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | Sanofi PasteurGlaxoSmithKline Biologicals SA | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20111123 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 83 | |
| RXA.5.2 | Text | hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | HAVRIX | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 6359RT33 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20120124 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | SKB | |
| RXA.17.2 | Text | GlaxoSmithKline Biologicals SA | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20120523 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 83 | |
| RXA.5.2 | Text | hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | HAVRIX | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 6359RT48 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20120911 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | Sanofi PasteurGlaxoSmithKline Biologicals SA | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20101023 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 94 | |
| RXA.5.2 | Text | measles, mumps, rubella, and varicella virus vaccine | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | ProQuad | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 01 | |
| RXA.9.2 | Text | historical | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 7W27V7491 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20101215 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | MSD | |
| RXA.17.2 | Text | Merck Sharp \T\ Dohme Corp | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20121122 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 94 | |
| RXA.5.2 | Text | measles, mumps, rubella, and varicella virus vaccine | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | ProQuad | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 7W87V3452 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20130413 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | MSD | |
| RXA.17.2 | Text | Merck Sharp \T\ Dohme Corp | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20150715 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 94 | Test Case Fixed |
| RXA.5.2 | Text | measles, mumps, rubella, and varicella virus vaccine | Test Case Fixed |
| RXA.5.3 | Name of Coding System | CVX | Test Case Fixed |
| RXA.5.5 | Alternate Text | ProQuad | Test Case Fixed |
| RXA.5.6 | Name of Alternate Coding System | NDC | Test Case Fixed |
| RXA.6 | Administered Amount | 0.5 | Test Case Fixed |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | mL | Test Case Fixed |
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | UCUM | Test Case Fixed |
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 00 | Test Case Fixed |
| RXA.9.2 | Text | New immunization record | Test Case Fixed |
| RXA.9.3 | Name of Coding System | NIP001 | Test Case Fixed |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Molina | Test Case Fixed |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | Sandra | Test Case Fixed |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 7W87V3687 | Test Case Fixed |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20150715 | Test Case Fixed |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | MSD | Test Case Fixed |
| RXA.17.2 | Text | Merck Sharp \T\ Dohme Corp | Test Case Fixed |
| RXA.17.3 | Name of Coding System | MVX | Test Case Fixed |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | Test Case Fixed |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LT | |
| RXR.2.2 | Text | Left Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | RT | |
| RXR.2.2 | Text | Right Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LT | |
| RXR.2.2 | Text | Left Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LT | |
| RXR.2.2 | Text | Left Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | RT | |
| RXR.2.2 | Text | Right Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LT | |
| RXR.2.2 | Text | Left Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | RT | |
| RXR.2.2 | Text | Right Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LT | |
| RXR.2.2 | Text | Left Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | RT | |
| RXR.2.2 | Text | Right Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C38299 | |
| RXR.1.2 | Text | SC | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | Subcutaneous | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C38299 | |
| RXR.1.2 | Text | SC | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | Subcutaneous | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C38299 | |
| RXR.1.2 | Text | SC | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | Subcutaneous | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LT | |
| RXR.2.2 | Text | Left Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C38299 | |
| RXR.1.2 | Text | SC | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | Subcutaneous | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LT | |
| RXR.2.2 | Text | Left Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | RT | |
| RXR.2.2 | Text | Right Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LT | |
| RXR.2.2 | Text | Left Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | RT | |
| RXR.2.2 | Text | Right Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LT | |
| RXR.2.2 | Text | Left Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | RT | |
| RXR.2.2 | Text | Right Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C38284 | |
| RXR.1.2 | Text | Nasal | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | Nasal | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | BN | |
| RXR.2.2 | Text | Bilateral Nares | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C38284 | |
| RXR.1.2 | Text | Nasal | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | Nasal | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | BN | |
| RXR.2.2 | Text | Bilateral Nares | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | RD | |
| RXR.2.2 | Text | Right Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C38299 | |
| RXR.1.2 | Text | Subcutaneous | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | Subcutaneous | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C38299 | |
| RXR.1.2 | Text | Subcutaneous | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | Subcutaneous | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C38299 | Test Case Fixed |
| RXR.1.2 | Text | Subcutaneous | Test Case Fixed |
| RXR.1.3 | Name of Coding System | NCIT | Test Case Fixed |
| RXR.1.5 | Alternate Text | Subcutaneous | Test Case Fixed |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | Test Case Fixed |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | Test Case Fixed |
| RXR.2.2 | Text | Left Deltoid | Test Case Fixed |
| RXR.2.3 | Name of Coding System | HL70163 | Test Case Fixed |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 21 | |
| OBX.2 | Value Type | CE | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 31044-1 | |
| OBX.3.2 | Text | Reaction | |
| OBX.3.3 | Name of Coding System | LN | |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20100522 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 2 | |
| OBX.2 | Value Type | TS | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 29768-9 | |
| OBX.3.2 | Text | VIS Publication Date | |
| OBX.3.3 | Name of Coding System | LN | |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.5.1 | Time | 20140819 | |
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 3 | |
| OBX.2 | Value Type | TS | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 29769-7 | |
| OBX.3.2 | Text | VIS Presentation Date | |
| OBX.3.3 | Name of Coding System | LN | |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.5.1 | Time | 20150715 | |
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 1 | |
| OBX.2 | Value Type | CE | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 64994-7 | |
| OBX.3.2 | Text | vaccine fund pgm elig cat | |
| OBX.3.3 | Name of Coding System | LN | |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 2 | |
| OBX.2 | Value Type | TS | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 29768-9 | |
| OBX.3.2 | Text | VIS Publication Date | |
| OBX.3.3 | Name of Coding System | LN | |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.5.1 | Time | 20100521 | |
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 3 | |
| OBX.2 | Value Type | TS | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 29769-7 | |
| OBX.3.2 | Text | VIS Presentation Date | |
| OBX.3.3 | Name of Coding System | LN | |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.5.1 | Time | 20150715 | |
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 1 | |
| OBX.2 | Value Type | CE | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 64994-7 | |
| OBX.3.2 | Text | vaccine fund pgm elig cat | |
| OBX.3.3 | Name of Coding System | LN | |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 1 | |
| OBX.2 | Value Type | CE | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 64994-7 | |
| OBX.3.2 | Text | vaccine fund pgm elig cat | |
| OBX.3.3 | Name of Coding System | LN | |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 21 | |
| OBX.2 | Value Type | CE | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 31044-1 | Test Case Fixed |
| OBX.3.2 | Text | Reaction | Test Case Fixed |
| OBX.3.3 | Name of Coding System | LN | Test Case Fixed |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Element | Data |
|---|---|
| Patient Name | Juana Mariana Gonzales |
| Mother's Maiden Name | Maria Acosta |
| ID Number | 123456 987633 |
| Date/Time of Birth | 12/23/2009 |
| Administrative Sex | Female |
| Patient Address | 4345 Standish Way Stamford CT 06903 USA |
| Patient Address 1 | 325 Shorline Drive Stamford CT 06901 |
| Local Number | (203)555-1212 |
| Race | Other Race |
| Ethnic Group | Hispanic or Latino |
| Birth Order |
| Element | Data |
|---|---|
| Immunization Registry Status | A |
| Immunization Registry Status Effective Date | 07/01/2012 |
| Publicity Code | Reminder/Recall - any method |
| Publicity Code Effective Date | 07/01/2012 |
| Protection Indicator | |
| Protection Indicator Effective Date |
| Element | Data |
|---|---|
| Name | Joanna Merida Gonzales |
| Relationship | Grandparent |
| Address | 4345 Standish Way Stamford CT 06901 |
| Phone Number | (203)555-1212 |
| Element | Data |
|---|---|
| Administered Code | hepatitis B vaccine, pediatric or pediatric/adolescent dosage |
| Date/Time Start of Administration | 11/23/2009 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | Lisa Sirtis |
| Substance Lot Number | 6332FK33 |
| Substance Expiration Date | 12/14/2010 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Shoreline Hospital |
| Entered By | Lisa Sirtis |
| Ordered By | Jane Carter |
| Element | Data |
|---|---|
| Administered Code | hepatitis B vaccine, unspecified formulation |
| Date/Time Start of Administration | 01/15/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical Immunization |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 6352FK1 |
| Substance Expiration Date | 10/01/2010 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Administered Code | hepatitis B vaccine, pediatric or pediatric/adolescent dosage |
| Date/Time Start of Administration | 10/30/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6352FK24 |
| Substance Expiration Date | 08/31/2012 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified |
| Date/Time Start of Administration | 01/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS2341 |
| Substance Expiration Date | 11/30/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 03/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS2433 |
| Substance Expiration Date | 09/04/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 05/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS3255 |
| Substance Expiration Date | 12/01/2010 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Reaction | fever of >40.5C (105F) within 48 hours of dose |
| Element | Data |
|---|---|
| Administered Code | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 02/21/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS249 |
| Substance Expiration Date | 03/01/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 08/31/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from other provider |
| Administering Provider | Linda Casera |
| Substance Lot Number | D643QS8243 |
| Substance Expiration Date | 09/01/2014 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | J Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 01/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M54K9245 |
| Substance Expiration Date | 03/24/2010 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 03/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M55K3342 |
| Substance Expiration Date | 10/30/2010 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 05/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M75K4566 |
| Substance Expiration Date | 05/23/2010 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 02/21/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M53K5534 |
| Substance Expiration Date | 02/22/2011 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 01/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D333PV2431 |
| Substance Expiration Date | 10/04/2010 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 03/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D333PV4344 |
| Substance Expiration Date | 03/23/2010 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 02/21/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from other provider |
| Administering Provider | Linda Casera |
| Substance Lot Number | D335PV9644 |
| Substance Expiration Date | 02/22/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | J Rodriguez |
| Element | Data |
|---|---|
| Administered Code | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 05/19/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | Parental decision |
| Completion Status | RE |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Administered Code | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 01/21/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P243V3281 |
| Substance Expiration Date | 01/30/2010 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 03/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P343V8321 |
| Substance Expiration Date | 03/30/2010 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 05/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P853V2164 |
| Substance Expiration Date | 08/30/2010 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 02/21/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P853V58532 |
| Substance Expiration Date | 04/18/2011 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | rotavirus, live, monovalent vaccine |
| Date/Time Start of Administration | 01/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RV533 |
| Substance Expiration Date | 02/15/2010 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | rotavirus, live, monovalent vaccine |
| Date/Time Start of Administration | 03/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RV932 |
| Substance Expiration Date | 05/10/2010 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 09/25/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D8043IN8734 |
| Substance Expiration Date | 03/12/2011 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 10/27/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D8043IN8734 |
| Substance Expiration Date | 03/12/2011 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 10/02/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D9334IN9333 |
| Substance Expiration Date | 05/22/2012 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 10/15/2013 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from parents written record |
| Administering Provider | Gina Ricci |
| Substance Lot Number | 8L4B3423 |
| Substance Expiration Date | 07/01/2014 |
| Substance Manufacturer Name | MedImmune, LLC |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | Nasal |
| Administration Site | Bilateral Nares |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Gina Ricci |
| Element | Data |
|---|---|
| Administered Code | influenza, live, intranasal, quadrivalent |
| Date/Time Start of Administration | 07/15/2015 |
| Administered Amount | 0.2 |
| Administered Units | |
| Administration Notes | New immunization record |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 8L4B3521 |
| Substance Expiration Date | 08/15/2015 |
| Substance Manufacturer Name | MedImmune,LLC |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | Nasal |
| Administration Site | Bilateral Nares |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| VIS Publication Date | 08/19/2014 |
| VIS Presentation Date | 07/15/2015 |
| vaccine fund pgm elig cat | Not VFC elig |
| Element | Data |
|---|---|
| Administered Code | influenza, live, intranasal, quadrivalent |
| Date/Time Start of Administration | 11/04/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D9553IN2243 |
| Substance Expiration Date | 04/30/2012 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule |
| Date/Time Start of Administration | 11/23/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RT33 |
| Substance Expiration Date | 01/24/2012 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule |
| Date/Time Start of Administration | 05/23/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RT48 |
| Substance Expiration Date | 09/11/2012 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Code | measles, mumps, rubella, and varicella virus vaccine |
| Date/Time Start of Administration | 10/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | historical |
| Administering Provider | J Martinez |
| Substance Lot Number | 7W27V7491 |
| Substance Expiration Date | 12/15/2010 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Code | measles, mumps, rubella, and varicella virus vaccine |
| Date/Time Start of Administration | 11/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7W87V3452 |
| Substance Expiration Date | 04/13/2013 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Code | measles, mumps, rubella, and varicella virus vaccine |
| Date/Time Start of Administration | 07/15/2015 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | New immunization record |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 7W87V3687 |
| Substance Expiration Date | 07/15/2015 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| VIS Publication Date | 05/21/2010 |
| VIS Presentation Date | 07/15/2015 |
| vaccine fund pgm elig cat | Not VFC elig |
| vaccine fund pgm elig cat | Not VFC elig |
| Reaction | persistent, inconsolable crying lasting > 3 hours within 48 hours of dose |
| Element | Data |
|---|---|
| Patient Name | Juana Mariana Gonzales |
| Mother's Maiden Name | Maria Acosta |
| ID Number | 123456 987633 |
| Date/Time of Birth | 12/23/2009 |
| Administrative Sex | Female |
| Patient Address | 4345 Standish Way Stamford CT 06903 USA |
| Patient Address 1 | 325 Shorline Drive Stamford CT 06901 |
| Local Number | (203)555-1212 |
| Race | Other Race |
| Ethnic Group | Hispanic or Latino |
| Birth Order |
| Element | Data |
|---|---|
| Immunization Registry Status | A |
| Immunization Registry Status Effective Date | 07/01/2012 |
| Publicity Code | Reminder/Recall - any method |
| Publicity Code Effective Date | 07/01/2012 |
| Protection Indicator | |
| Protection Indicator Effective Date |
| Element | Data |
|---|---|
| Name | Joanna Merida Gonzales |
| Relationship | Grandparent |
| Address | 4345 Standish Way Stamford CT 06901 |
| Phone Number | (203)555-1212 |
| Element | Data |
|---|---|
| Administered Code | hepatitis B vaccine, pediatric or pediatric/adolescent dosage |
| Date/Time Start of Administration | 11/23/2009 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | Lisa Sirtis |
| Substance Lot Number | 6332FK33 |
| Substance Expiration Date | 12/14/2010 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Shoreline Hospital |
| Entered By | Lisa Sirtis |
| Ordered By | Jane Carter |
| Element | Data |
|---|---|
| Administered Code | hepatitis B vaccine, unspecified formulation |
| Date/Time Start of Administration | 01/15/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical Immunization |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 6352FK1 |
| Substance Expiration Date | 10/01/2010 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Administered Code | hepatitis B vaccine, pediatric or pediatric/adolescent dosage |
| Date/Time Start of Administration | 10/30/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6352FK24 |
| Substance Expiration Date | 08/31/2012 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified |
| Date/Time Start of Administration | 01/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS2341 |
| Substance Expiration Date | 11/30/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 03/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS2433 |
| Substance Expiration Date | 09/04/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 05/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS3255 |
| Substance Expiration Date | 12/01/2010 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Reaction | fever of >40.5C (105F) within 48 hours of dose |
| Element | Data |
|---|---|
| Administered Code | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 02/21/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS249 |
| Substance Expiration Date | 03/01/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 08/31/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from other provider |
| Administering Provider | Linda Casera |
| Substance Lot Number | D643QS8243 |
| Substance Expiration Date | 09/01/2014 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | J Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 01/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M54K9245 |
| Substance Expiration Date | 03/24/2010 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 03/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M55K3342 |
| Substance Expiration Date | 10/30/2010 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 05/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M75K4566 |
| Substance Expiration Date | 05/23/2010 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 02/21/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M53K5534 |
| Substance Expiration Date | 02/22/2011 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 01/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D333PV2431 |
| Substance Expiration Date | 10/04/2010 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 03/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D333PV4344 |
| Substance Expiration Date | 03/23/2010 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 02/21/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from other provider |
| Administering Provider | Linda Casera |
| Substance Lot Number | D335PV9644 |
| Substance Expiration Date | 02/22/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | J Rodriguez |
| Element | Data |
|---|---|
| Administered Code | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 05/19/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | Parental decision |
| Completion Status | RE |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Administered Code | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 01/21/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P243V3281 |
| Substance Expiration Date | 01/30/2010 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 03/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P343V8321 |
| Substance Expiration Date | 03/30/2010 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 05/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P853V2164 |
| Substance Expiration Date | 08/30/2010 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 02/21/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P853V58532 |
| Substance Expiration Date | 04/18/2011 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | rotavirus, live, monovalent vaccine |
| Date/Time Start of Administration | 01/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RV533 |
| Substance Expiration Date | 02/15/2010 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | rotavirus, live, monovalent vaccine |
| Date/Time Start of Administration | 03/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RV932 |
| Substance Expiration Date | 05/10/2010 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 09/25/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D8043IN8734 |
| Substance Expiration Date | 03/12/2011 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 10/27/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D8043IN8734 |
| Substance Expiration Date | 03/12/2011 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 10/02/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D9334IN9333 |
| Substance Expiration Date | 05/22/2012 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 10/15/2013 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from parents written record |
| Administering Provider | Gina Ricci |
| Substance Lot Number | 8L4B3423 |
| Substance Expiration Date | 07/01/2014 |
| Substance Manufacturer Name | MedImmune, LLC |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | Nasal |
| Administration Site | Bilateral Nares |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Gina Ricci |
| Element | Data |
|---|---|
| Administered Code | influenza, live, intranasal, quadrivalent |
| Date/Time Start of Administration | 07/15/2015 |
| Administered Amount | 0.2 |
| Administered Units | |
| Administration Notes | New immunization record |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 8L4B3521 |
| Substance Expiration Date | 08/15/2015 |
| Substance Manufacturer Name | MedImmune,LLC |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | Nasal |
| Administration Site | Bilateral Nares |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| VIS Publication Date | 08/19/2014 |
| VIS Presentation Date | 07/15/2015 |
| vaccine fund pgm elig cat | Not VFC elig |
| Element | Data |
|---|---|
| Administered Code | influenza, live, intranasal, quadrivalent |
| Date/Time Start of Administration | 11/04/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D9553IN2243 |
| Substance Expiration Date | 04/30/2012 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule |
| Date/Time Start of Administration | 11/23/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RT33 |
| Substance Expiration Date | 01/24/2012 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule |
| Date/Time Start of Administration | 05/23/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RT48 |
| Substance Expiration Date | 09/11/2012 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Code | measles, mumps, rubella, and varicella virus vaccine |
| Date/Time Start of Administration | 10/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | historical |
| Administering Provider | J Martinez |
| Substance Lot Number | 7W27V7491 |
| Substance Expiration Date | 12/15/2010 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Code | measles, mumps, rubella, and varicella virus vaccine |
| Date/Time Start of Administration | 11/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7W87V3452 |
| Substance Expiration Date | 04/13/2013 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Code | measles, mumps, rubella, and varicella virus vaccine |
| Date/Time Start of Administration | 07/15/2015 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | New immunization record |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 7W87V3687 |
| Substance Expiration Date | 07/15/2015 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| VIS Publication Date | 05/21/2010 |
| VIS Presentation Date | 07/15/2015 |
| vaccine fund pgm elig cat | Not VFC elig |
| vaccine fund pgm elig cat | Not VFC elig |
| Reaction | persistent, inconsolable crying lasting > 3 hours within 48 hours of dose |
| No Description |
| No Comments |
| No PreCondition |
| No PostCondition |
| No Test Objectives |
| No evaluation criteria |
| No Note |
Following the vaccinations given during the visit, the EMR transmits an Immunization report to the Immunization Registry using the VXU/Z22. The Vaccination report includes all newly administered vaccines. The report MAY send the immunizations that the EMR imported from the IIS. |
The Report must include all newly administered vaccines in any order. The report may include the information imported from the IIS. |
The vaccines for the visit have been administered. |
The Immunization Report has been transmitted to the IIS using a valid Z22 VXU in accordance with the test data correctly and without omission. |
Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries. |
The VXU/Z22 message passes validation using the NIST Immunization VXU Validation Tool (Z22) (context-free). The content of the message correctly reflects the test data (context-based) in accordance with the Test Data Specification and the Message Content. |
No Note |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| MSH.1 | Field Separator | | | |
| MSH.2 | Encoding Characters | ^~\& | |
| MSH.3 | Sending Application | ||
| MSH.3.1 | Namespace ID | Test EHR Application | |
| MSH.3.2 | Universal ID | ||
| MSH.3.3 | Universal ID Type | ||
| MSH.4 | Sending Facility | ||
| MSH.4.1 | Namespace ID | X68 | |
| MSH.4.2 | Universal ID | ||
| MSH.4.3 | Universal ID Type | ||
| MSH.5 | Receiving Application | ||
| MSH.5.1 | Namespace ID | ||
| MSH.5.2 | Universal ID | ||
| MSH.5.3 | Universal ID Type | ||
| MSH.6 | Receiving Facility | ||
| MSH.6.1 | Namespace ID | NIST Test Iz Reg | |
| MSH.6.2 | Universal ID | ||
| MSH.6.3 | Universal ID Type | ||
| MSH.7 | Date/Time Of Message | ||
| MSH.7.1 | Time | 20120701082240-0500 | |
| MSH.9 | Message Type | ||
| MSH.9.1 | Message Code | VXU | |
| MSH.9.2 | Trigger Event | V04 | |
| MSH.9.3 | Message Structure | VXU_V04 | |
| MSH.10 | Message Control ID | NIST-IZ-001.00 | |
| MSH.11 | Processing ID | ||
| MSH.11.1 | Processing ID | P | |
| MSH.12 | Version ID | ||
| MSH.12.1 | Version ID | 2.5.1 | |
| MSH.15 | Accept Acknowledgment Type | ER | |
| MSH.16 | Application Acknowledgment Type | AL | |
| MSH.21 | Message Profile Identifier | ||
| MSH.21.1 | Entity Identifier | Z22 | |
| MSH.21.2 | Namespace ID | CDCPHINVS | |
| MSH.21.3 | Universal ID | ||
| MSH.21.4 | Universal ID Type | ||
| MSH.22 | Sending Responsible Organization | ||
| MSH.22.1 | Organization Name | ||
| MSH.22.6 | Assigning Authority | ||
| MSH.22.6.1 | Namespace ID | ||
| MSH.22.6.2 | Universal ID | ||
| MSH.22.6.3 | Universal ID Type | ||
| MSH.22.7 | Identifier Type Code | ||
| MSH.22.10 | Organization Identifier | ||
| MSH.23 | Receiving Responsible Organization | ||
| MSH.23.1 | Organization Name | ||
| MSH.23.6 | Assigning Authority | ||
| MSH.23.6.1 | Namespace ID | ||
| MSH.23.6.2 | Universal ID | ||
| MSH.23.6.3 | Universal ID Type | ||
| MSH.23.7 | Identifier Type Code | ||
| MSH.23.10 | Organization Identifier |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| PID.1 | Set ID - PID | 1 | |
| PID.3 | Patient Identifier List | ||
| PID.3.1 | ID Number | 123456 | |
| PID.3.3 | Check Digit Scheme | ||
| PID.3.4 | Assigning Authority | ||
| PID.3.4.1 | Namespace ID | MYEHR | |
| PID.3.4.2 | Universal ID | ||
| PID.3.4.3 | Universal ID Type | ||
| PID.3.5 | Identifier Type Code | MR | |
| PID.3 | Patient Identifier List | ||
| PID.3.1 | ID Number | 987633 | |
| PID.3.3 | Check Digit Scheme | ||
| PID.3.4 | Assigning Authority | ||
| PID.3.4.1 | Namespace ID | MYIIS | |
| PID.3.4.2 | Universal ID | ||
| PID.3.4.3 | Universal ID Type | ||
| PID.3.5 | Identifier Type Code | SR | |
| PID.5 | Patient Name | ||
| PID.5.1 | Family Name | ||
| PID.5.1.1 | Surname | Gonzales | |
| PID.5.1.2 | Own Surname Prefix | ||
| PID.5.1.3 | Own Surname | ||
| PID.5.1.4 | Surname Prefix From Partner/Spouse | ||
| PID.5.1.5 | Surname From Partner/Spouse | ||
| PID.5.2 | Given Name | Juan | Test Case Fixed |
| PID.5.3 | Second and Further Given Names or Initials Thereof | Marcel | Test Case Fixed |
| PID.5.7 | Name Type Code | L | Test Case Fixed |
| PID.6 | Mother's Maiden Name | ||
| PID.6.1 | Family Name | ||
| PID.6.1.1 | Surname | Morales | Test Case Fixed |
| PID.6.1.2 | Own Surname Prefix | ||
| PID.6.1.3 | Own Surname | ||
| PID.6.1.4 | Surname Prefix From Partner/Spouse | ||
| PID.6.1.5 | Surname From Partner/Spouse | ||
| PID.6.7 | Name Type Code | M | Test Case Fixed |
| PID.7 | Date/Time of Birth | ||
| PID.7.1 | Time | 201111231100 | Test Case Fixed |
| PID.8 | Administrative Sex | M | Test Case Fixed |
| PID.10 | Race | ||
| PID.10.1 | Identifier | 2131-1 | Test Case Fixed |
| PID.10.2 | Text | Other Race | Test Case Fixed |
| PID.10.3 | Name of Coding System | HL70005 | Test Case Fixed |
| PID.10.5 | Alternate Text | ||
| PID.10.6 | Name of Alternate Coding System | ||
| PID.11 | Patient Address | ||
| PID.11.1 | Street Address | ||
| PID.11.1.1 | Street or Mailing Address | 4623 Standish Way | Test Case Fixed |
| PID.11.1.2 | Street Name | ||
| PID.11.1.3 | Dwelling Number | ||
| PID.11.2 | Other Designation | ||
| PID.11.3 | City | Stamford | Test Case Fixed |
| PID.11.4 | State or Province | CT | Test Case Fixed |
| PID.11.5 | Zip or Postal Code | 06903 | Test Case Fixed |
| PID.11.6 | Country | USA | Test Case Fixed |
| PID.11.7 | Address Type | L | Test Case Fixed |
| PID.13 | Phone Number - Home | ||
| PID.13.2 | Telecommunication Use Code | PRN | Test Case Fixed |
| PID.13.3 | Telecommunication Equipment Type | PH | Test Case Fixed |
| PID.13.4 | Email Address | ||
| PID.13.6 | Area/City Code | 203 | Test Case Fixed |
| PID.13.7 | Local Number | 5551213 | Test Case Fixed |
| PID.22 | Ethnic Group | ||
| PID.22.1 | Identifier | 2135-2 | Test Case Fixed |
| PID.22.2 | Text | Hispanic or Latino | Test Case Fixed |
| PID.22.3 | Name of Coding System | CDCREC | Test Case Fixed |
| PID.22.5 | Alternate Text | ||
| PID.22.6 | Name of Alternate Coding System | ||
| PID.24 | Multiple Birth Indicator | ||
| PID.25 | Birth Order | ||
| PID.29 | Patient Death Date and Time | ||
| PID.29.1 | Time | ||
| PID.30 | Patient Death Indicator |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| PD1.11 | Publicity Code | ||
| PD1.11.1 | Identifier | 02 | |
| PD1.11.2 | Text | Reminder/Recall - any method | |
| PD1.11.3 | Name of Coding System | HL70215 | |
| PD1.11.5 | Alternate Text | ||
| PD1.11.6 | Name of Alternate Coding System | ||
| PD1.12 | Protection Indicator | ||
| PD1.13 | Protection Indicator Effective Date | ||
| PD1.16 | Immunization Registry Status | A | |
| PD1.17 | Immunization Registry Status Effective Date | 20120701 | |
| PD1.18 | Publicity Code Effective Date | 20120701 |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| NK1.1 | Set ID - NK1 | 1 | |
| NK1.2 | Name | ||
| NK1.2.1 | Family Name | ||
| NK1.2.1.1 | Surname | Gonzales | Test Case Fixed |
| NK1.2.1.2 | Own Surname Prefix | ||
| NK1.2.1.3 | Own Surname | ||
| NK1.2.1.4 | Surname Prefix From Partner/Spouse | ||
| NK1.2.1.5 | Surname From Partner/Spouse | ||
| NK1.2.2 | Given Name | Manuel | Test Case Fixed |
| NK1.2.3 | Second and Further Given Names or Initials Thereof | Marcel | Test Case Fixed |
| NK1.2.7 | Name Type Code | L | Test Case Fixed |
| NK1.3 | Relationship | ||
| NK1.3.1 | Identifier | FTH | Test Case Fixed |
| NK1.3.2 | Text | Father | Test Case Fixed |
| NK1.3.3 | Name of Coding System | HL70063 | Test Case Fixed |
| NK1.3.5 | Alternate Text | ||
| NK1.3.6 | Name of Alternate Coding System | ||
| NK1.4 | Address | ||
| NK1.4.1 | Street Address | ||
| NK1.4.1.1 | Street or Mailing Address | 4623 Standish Way | Test Case Fixed |
| NK1.4.1.2 | Street Name | ||
| NK1.4.1.3 | Dwelling Number | ||
| NK1.4.2 | Other Designation | ||
| NK1.4.3 | City | Stamford | Test Case Fixed |
| NK1.4.4 | State or Province | CT | Test Case Fixed |
| NK1.4.5 | Zip or Postal Code | 06903 | Test Case Fixed |
| NK1.4.6 | Country | ||
| NK1.4.7 | Address Type | L | |
| NK1.5 | Phone Number | ||
| NK1.5.2 | Telecommunication Use Code | PRN | Test Case Fixed |
| NK1.5.3 | Telecommunication Equipment Type | PH | Test Case Fixed |
| NK1.5.4 | Email Address | ||
| NK1.5.6 | Area/City Code | 203 | Test Case Fixed |
| NK1.5.7 | Local Number | 5551213 | Test Case Fixed |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Sirtis | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | Lisa | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Carter | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Jane | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | SH | |
| ORC.17.2 | Text | Shoreline Hospital | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Molina | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | Sandra | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Smith | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Frank | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | SP | |
| ORC.17.2 | Text | Shoreline Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Molina | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | Sandra | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Smith | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Frank | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | SP | |
| ORC.17.2 | Text | Shoreline Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20111123 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 08 | |
| RXA.5.2 | Text | Hepatitis B | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | ENGERIX-B | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 6332FK34 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20111214 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | SKB | |
| RXA.17.2 | Text | GlaxoSmithKline Biologicals SA | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20111223 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 08 | |
| RXA.5.2 | Text | Hepatitis B | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | ENGERIX-B | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 6352FK2 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20111001 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | SKB | |
| RXA.17.2 | Text | GlaxoSmithKline Biologicals SA | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20150715 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 08 | |
| RXA.5.2 | Text | Hepatitis B | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | ENGERIX-B | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 0.5 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | mL | |
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | UCUM | |
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 00 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Molina | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | Sandra | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 6332FK26 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20150825 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | SKB | |
| RXA.17.2 | Text | GlaxoSmithKline Biologicals SA | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20120122 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 106 | |
| RXA.5.2 | Text | DTaP | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | DAPTACEL | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D409QS2342 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20121130 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | Sanofi Pasteur Inc | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20120322 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 106 | |
| RXA.5.2 | Text | DTaP | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | DAPTACEL | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D409QS2434 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20120904 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | Sanofi Pasteur Inc | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20120521 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 106 | |
| RXA.5.2 | Text | DTaP | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | DAPTACEL | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D409QS250 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20140103 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | Sanofi Pasteur Inc | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20130220 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 106 | |
| RXA.5.2 | Text | DTaP | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | DAPTACEL | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D409QS250 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20140103 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | Sanofi Pasteur Inc | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20120122 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 49 | |
| RXA.5.2 | Text | Hib | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | PedvaxHIB | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 7M54K9255 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20120324 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | MSD | |
| RXA.17.2 | Text | Merck Sharp and Dohme Corp. | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20120322 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 49 | |
| RXA.5.2 | Text | Hib | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | PedvaxHIB | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 7M55K3343 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20121030 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | MSD | |
| RXA.17.2 | Text | Merck Sharp and Dohme Corp. | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20120512 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 49 | |
| RXA.5.2 | Text | Hib | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | PedvaxHIB | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 7M75K4577 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20120523 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | MSD | |
| RXA.17.2 | Text | Merck Sharp and Dohme Corp. | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20120222 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 49 | |
| RXA.5.2 | Text | Hib | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | PedvaxHIB | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 7M53K5535 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20120222 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | MSD | |
| RXA.17.2 | Text | Merck Sharp and Dohme Corp. | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20120122 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 10 | |
| RXA.5.2 | Text | Polio (IPV) | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | IPOL | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D333PV2444 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20120410 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | MSanofi Pasteur Inc. | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20120322 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 10 | |
| RXA.5.2 | Text | Polio (IPV) | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | IPOL | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D333PV4343 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20120323 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | MSanofi Pasteur Inc. | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20120521 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 10 | |
| RXA.5.2 | Text | Polio (IPV) | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | IPOL | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D333PV4343 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20120323 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | MSanofi Pasteur Inc. | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20120122 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 133 | |
| RXA.5.2 | Text | Pneumococcal conjugate (PCV13) | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | PREVNAR 13 | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | P243V3321 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20120130 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PFR | |
| RXA.17.2 | Text | Pfizer, Inc | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20120322 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 133 | |
| RXA.5.2 | Text | Pneumococcal conjugate (PCV13) | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | PREVNAR 13 | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | P343V8445 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20120330 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PFR | |
| RXA.17.2 | Text | Pfizer, Inc | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20120521 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 133 | |
| RXA.5.2 | Text | Pneumococcal conjugate (PCV13) | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | PREVNAR 13 | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | P853V2175 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20120830 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PFR | |
| RXA.17.2 | Text | Pfizer, Inc | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20121122 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 133 | |
| RXA.5.2 | Text | Pneumococcal conjugate (PCV13) | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | PREVNAR 13 | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | P853V58544 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20130118 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PFR | |
| RXA.17.2 | Text | Pfizer, Inc | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20121122 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 119 | |
| RXA.5.2 | Text | Rotavirus | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | ROTARIX | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 6359RV543 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20120215 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | SKB | |
| RXA.17.2 | Text | GlaxoSmithKline Biologicals SA | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20120322 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 119 | |
| RXA.5.2 | Text | Rotavirus | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | ROTARIX | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 6359RV933 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20120510 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | SKB | |
| RXA.17.2 | Text | GlaxoSmithKline Biologicals SA | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20120922 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 161 | |
| RXA.5.2 | Text | Influenza | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | FLUZONE QUADRIVALENT | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D8043IN8738 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20130312 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | Sanofi Pasteur | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20121022 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 161 | |
| RXA.5.2 | Text | Influenza | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | FLUZONE QUADRIVALENT | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D8043IN8798 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20130312 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | Sanofi Pasteur | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20131030 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 161 | |
| RXA.5.2 | Text | Influenza | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | FLUZONE QUADRIVALENT | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D9334IN9433 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20140522 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | Sanofi Pasteur | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20150715 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 161 | |
| RXA.5.2 | Text | Influenza | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | FLUZONE QUADRIVALENT | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 0.25 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | mL | |
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | UCUM | |
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 00 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Molina | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | Sandra | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D8043IN8855 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20150828 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | Sanofi Pasteur | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20130521 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 83 | |
| RXA.5.2 | Text | Hepatitis A | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | HAVRIX | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 6359RT35 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20140104 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | SKB | |
| RXA.17.2 | Text | GlaxoSmithKline Biologicals SA | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20131201 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 83 | |
| RXA.5.2 | Text | Hepatitis A | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | HAVRIX | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 6359RT47 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20130911 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | SKB | |
| RXA.17.2 | Text | GlaxoSmithKline Biologicals SA | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20130112 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 94 | |
| RXA.5.2 | Text | MMR and Varicella | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | ProQuad | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 7W27V7632 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20161215 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | MSD | |
| RXA.17.2 | Text | Merck Sharp and Dohme Corp. | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LT | |
| RXR.2.2 | Text | Left Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | RT | |
| RXR.2.2 | Text | Right Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LT | |
| RXR.2.2 | Text | Left Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LT | |
| RXR.2.2 | Text | Left Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | RT | |
| RXR.2.2 | Text | Right Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LT | |
| RXR.2.2 | Text | Left Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | RT | |
| RXR.2.2 | Text | Right Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | SC | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | SC | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | SC | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | SC | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | SC | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | SC | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LT | |
| RXR.2.2 | Text | Left Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LT | |
| RXR.2.2 | Text | Left Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | RT | |
| RXR.2.2 | Text | Right Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LT | |
| RXR.2.2 | Text | Left Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | RT | |
| RXR.2.2 | Text | Thigh Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LT | |
| RXR.2.2 | Text | Left Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | RT | |
| RXR.2.2 | Text | Right Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | RD | |
| RXR.2.2 | Text | Right Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | SC | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | SC | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LT | |
| RXR.2.2 | Text | Left Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 2 | |
| OBX.2 | Value Type | TS | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 29768-9 | |
| OBX.3.2 | Text | VIS Publication Date | |
| OBX.3.3 | Name of Coding System | LN | |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.5.1 | Time | 20120202 | |
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 3 | |
| OBX.2 | Value Type | TS | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 29769-7 | |
| OBX.3.2 | Text | VIS Presentation Date | |
| OBX.3.3 | Name of Coding System | LN | |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.5.1 | Time | 20150715 | |
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 1 | |
| OBX.2 | Value Type | CE | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 64994-7 | |
| OBX.3.2 | Text | vaccine fund pgm elig cat | |
| OBX.3.3 | Name of Coding System | LN | |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 2 | |
| OBX.2 | Value Type | TS | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 29768-9 | |
| OBX.3.2 | Text | VIS Publication Date | |
| OBX.3.3 | Name of Coding System | LN | |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.5.1 | Time | 20140819 | |
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 3 | |
| OBX.2 | Value Type | TS | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 29769-7 | |
| OBX.3.2 | Text | VIS Presentation Date | |
| OBX.3.3 | Name of Coding System | LN | |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.5.1 | Time | 20150715 | |
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 1 | |
| OBX.2 | Value Type | CE | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 64994-7 | |
| OBX.3.2 | Text | vaccine fund pgm elig cat | |
| OBX.3.3 | Name of Coding System | LN | |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| MSH.1 | Field Separator | | | |
| MSH.2 | Encoding Characters | ^~\& | |
| MSH.3 | Sending Application | ||
| MSH.3.1 | Namespace ID | Test EHR Application | |
| MSH.3.2 | Universal ID | ||
| MSH.3.3 | Universal ID Type | ||
| MSH.4 | Sending Facility | ||
| MSH.4.1 | Namespace ID | X68 | |
| MSH.4.2 | Universal ID | ||
| MSH.4.3 | Universal ID Type | ||
| MSH.5 | Receiving Application | ||
| MSH.5.1 | Namespace ID | ||
| MSH.5.2 | Universal ID | ||
| MSH.5.3 | Universal ID Type | ||
| MSH.6 | Receiving Facility | ||
| MSH.6.1 | Namespace ID | NIST Test Iz Reg | |
| MSH.6.2 | Universal ID | ||
| MSH.6.3 | Universal ID Type | ||
| MSH.7 | Date/Time Of Message | ||
| MSH.7.1 | Time | 20120701082240-0500 | |
| MSH.9 | Message Type | ||
| MSH.9.1 | Message Code | VXU | |
| MSH.9.2 | Trigger Event | V04 | |
| MSH.9.3 | Message Structure | VXU_V04 | |
| MSH.10 | Message Control ID | NIST-IZ-001.00 | |
| MSH.11 | Processing ID | ||
| MSH.11.1 | Processing ID | P | |
| MSH.12 | Version ID | ||
| MSH.12.1 | Version ID | 2.5.1 | |
| MSH.15 | Accept Acknowledgment Type | ER | |
| MSH.16 | Application Acknowledgment Type | AL | |
| MSH.21 | Message Profile Identifier | ||
| MSH.21.1 | Entity Identifier | Z22 | |
| MSH.21.2 | Namespace ID | CDCPHINVS | |
| MSH.21.3 | Universal ID | ||
| MSH.21.4 | Universal ID Type | ||
| MSH.22 | Sending Responsible Organization | ||
| MSH.22.1 | Organization Name | ||
| MSH.22.6 | Assigning Authority | ||
| MSH.22.6.1 | Namespace ID | ||
| MSH.22.6.2 | Universal ID | ||
| MSH.22.6.3 | Universal ID Type | ||
| MSH.22.7 | Identifier Type Code | ||
| MSH.22.10 | Organization Identifier | ||
| MSH.23 | Receiving Responsible Organization | ||
| MSH.23.1 | Organization Name | ||
| MSH.23.6 | Assigning Authority | ||
| MSH.23.6.1 | Namespace ID | ||
| MSH.23.6.2 | Universal ID | ||
| MSH.23.6.3 | Universal ID Type | ||
| MSH.23.7 | Identifier Type Code | ||
| MSH.23.10 | Organization Identifier |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| PID.1 | Set ID - PID | 1 | |
| PID.3 | Patient Identifier List | ||
| PID.3.1 | ID Number | 123456 | |
| PID.3.3 | Check Digit Scheme | ||
| PID.3.4 | Assigning Authority | ||
| PID.3.4.1 | Namespace ID | MYEHR | |
| PID.3.4.2 | Universal ID | ||
| PID.3.4.3 | Universal ID Type | ||
| PID.3.5 | Identifier Type Code | MR | |
| PID.3 | Patient Identifier List | ||
| PID.3.1 | ID Number | 987633 | |
| PID.3.3 | Check Digit Scheme | ||
| PID.3.4 | Assigning Authority | ||
| PID.3.4.1 | Namespace ID | MYIIS | |
| PID.3.4.2 | Universal ID | ||
| PID.3.4.3 | Universal ID Type | ||
| PID.3.5 | Identifier Type Code | SR | |
| PID.5 | Patient Name | ||
| PID.5.1 | Family Name | ||
| PID.5.1.1 | Surname | Gonzales | |
| PID.5.1.2 | Own Surname Prefix | ||
| PID.5.1.3 | Own Surname | ||
| PID.5.1.4 | Surname Prefix From Partner/Spouse | ||
| PID.5.1.5 | Surname From Partner/Spouse | ||
| PID.5.2 | Given Name | Juan | Test Case Fixed |
| PID.5.3 | Second and Further Given Names or Initials Thereof | Marcel | Test Case Fixed |
| PID.5.7 | Name Type Code | L | Test Case Fixed |
| PID.6 | Mother's Maiden Name | ||
| PID.6.1 | Family Name | ||
| PID.6.1.1 | Surname | Morales | Test Case Fixed |
| PID.6.1.2 | Own Surname Prefix | ||
| PID.6.1.3 | Own Surname | ||
| PID.6.1.4 | Surname Prefix From Partner/Spouse | ||
| PID.6.1.5 | Surname From Partner/Spouse | ||
| PID.6.7 | Name Type Code | M | Test Case Fixed |
| PID.7 | Date/Time of Birth | ||
| PID.7.1 | Time | 201111231100 | Test Case Fixed |
| PID.8 | Administrative Sex | M | Test Case Fixed |
| PID.10 | Race | ||
| PID.10.1 | Identifier | 2131-1 | Test Case Fixed |
| PID.10.2 | Text | Other Race | Test Case Fixed |
| PID.10.3 | Name of Coding System | HL70005 | Test Case Fixed |
| PID.10.5 | Alternate Text | ||
| PID.10.6 | Name of Alternate Coding System | ||
| PID.11 | Patient Address | ||
| PID.11.1 | Street Address | ||
| PID.11.1.1 | Street or Mailing Address | 4623 Standish Way | Test Case Fixed |
| PID.11.1.2 | Street Name | ||
| PID.11.1.3 | Dwelling Number | ||
| PID.11.2 | Other Designation | ||
| PID.11.3 | City | Stamford | Test Case Fixed |
| PID.11.4 | State or Province | CT | Test Case Fixed |
| PID.11.5 | Zip or Postal Code | 06903 | Test Case Fixed |
| PID.11.6 | Country | USA | Test Case Fixed |
| PID.11.7 | Address Type | L | Test Case Fixed |
| PID.13 | Phone Number - Home | ||
| PID.13.2 | Telecommunication Use Code | PRN | Test Case Fixed |
| PID.13.3 | Telecommunication Equipment Type | PH | Test Case Fixed |
| PID.13.4 | Email Address | ||
| PID.13.6 | Area/City Code | 203 | Test Case Fixed |
| PID.13.7 | Local Number | 5551213 | Test Case Fixed |
| PID.22 | Ethnic Group | ||
| PID.22.1 | Identifier | 2135-2 | Test Case Fixed |
| PID.22.2 | Text | Hispanic or Latino | Test Case Fixed |
| PID.22.3 | Name of Coding System | CDCREC | Test Case Fixed |
| PID.22.5 | Alternate Text | ||
| PID.22.6 | Name of Alternate Coding System | ||
| PID.24 | Multiple Birth Indicator | ||
| PID.25 | Birth Order | ||
| PID.29 | Patient Death Date and Time | ||
| PID.29.1 | Time | ||
| PID.30 | Patient Death Indicator |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| PD1.11 | Publicity Code | ||
| PD1.11.1 | Identifier | 02 | |
| PD1.11.2 | Text | Reminder/Recall - any method | |
| PD1.11.3 | Name of Coding System | HL70215 | |
| PD1.11.5 | Alternate Text | ||
| PD1.11.6 | Name of Alternate Coding System | ||
| PD1.12 | Protection Indicator | ||
| PD1.13 | Protection Indicator Effective Date | ||
| PD1.16 | Immunization Registry Status | A | |
| PD1.17 | Immunization Registry Status Effective Date | 20120701 | |
| PD1.18 | Publicity Code Effective Date | 20120701 |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| NK1.1 | Set ID - NK1 | 1 | |
| NK1.2 | Name | ||
| NK1.2.1 | Family Name | ||
| NK1.2.1.1 | Surname | Gonzales | Test Case Fixed |
| NK1.2.1.2 | Own Surname Prefix | ||
| NK1.2.1.3 | Own Surname | ||
| NK1.2.1.4 | Surname Prefix From Partner/Spouse | ||
| NK1.2.1.5 | Surname From Partner/Spouse | ||
| NK1.2.2 | Given Name | Manuel | Test Case Fixed |
| NK1.2.3 | Second and Further Given Names or Initials Thereof | Marcel | Test Case Fixed |
| NK1.2.7 | Name Type Code | L | Test Case Fixed |
| NK1.3 | Relationship | ||
| NK1.3.1 | Identifier | FTH | Test Case Fixed |
| NK1.3.2 | Text | Father | Test Case Fixed |
| NK1.3.3 | Name of Coding System | HL70063 | Test Case Fixed |
| NK1.3.5 | Alternate Text | ||
| NK1.3.6 | Name of Alternate Coding System | ||
| NK1.4 | Address | ||
| NK1.4.1 | Street Address | ||
| NK1.4.1.1 | Street or Mailing Address | 4623 Standish Way | Test Case Fixed |
| NK1.4.1.2 | Street Name | ||
| NK1.4.1.3 | Dwelling Number | ||
| NK1.4.2 | Other Designation | ||
| NK1.4.3 | City | Stamford | Test Case Fixed |
| NK1.4.4 | State or Province | CT | Test Case Fixed |
| NK1.4.5 | Zip or Postal Code | 06903 | Test Case Fixed |
| NK1.4.6 | Country | ||
| NK1.4.7 | Address Type | L | |
| NK1.5 | Phone Number | ||
| NK1.5.2 | Telecommunication Use Code | PRN | Test Case Fixed |
| NK1.5.3 | Telecommunication Equipment Type | PH | Test Case Fixed |
| NK1.5.4 | Email Address | ||
| NK1.5.6 | Area/City Code | 203 | Test Case Fixed |
| NK1.5.7 | Local Number | 5551213 | Test Case Fixed |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Sirtis | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | Lisa | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Carter | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Jane | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | SH | |
| ORC.17.2 | Text | Shoreline Hospital | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Molina | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | Sandra | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Smith | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Frank | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | SP | |
| ORC.17.2 | Text | Shoreline Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Molina | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | Sandra | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Smith | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Frank | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | SP | |
| ORC.17.2 | Text | Shoreline Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Martinez | |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | J. | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Rodriguez | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | J. | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | OP | |
| ORC.17.2 | Text | Oceanview Pediatrics | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20111123 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 08 | |
| RXA.5.2 | Text | Hepatitis B | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | ENGERIX-B | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 6332FK34 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20111214 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | SKB | |
| RXA.17.2 | Text | GlaxoSmithKline Biologicals SA | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20111223 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 08 | |
| RXA.5.2 | Text | Hepatitis B | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | ENGERIX-B | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 6352FK2 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20111001 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | SKB | |
| RXA.17.2 | Text | GlaxoSmithKline Biologicals SA | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20150715 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 08 | |
| RXA.5.2 | Text | Hepatitis B | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | ENGERIX-B | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 0.5 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | mL | |
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | UCUM | |
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 00 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Molina | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | Sandra | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 6332FK26 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20150825 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | SKB | |
| RXA.17.2 | Text | GlaxoSmithKline Biologicals SA | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20120122 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 106 | |
| RXA.5.2 | Text | DTaP | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | DAPTACEL | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D409QS2342 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20121130 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | Sanofi Pasteur Inc | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20120322 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 106 | |
| RXA.5.2 | Text | DTaP | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | DAPTACEL | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D409QS2434 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20120904 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | Sanofi Pasteur Inc | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20120521 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 106 | |
| RXA.5.2 | Text | DTaP | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | DAPTACEL | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D409QS250 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20140103 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | Sanofi Pasteur Inc | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20130220 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 106 | |
| RXA.5.2 | Text | DTaP | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | DAPTACEL | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D409QS250 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20140103 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | Sanofi Pasteur Inc | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20120122 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 49 | |
| RXA.5.2 | Text | Hib | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | PedvaxHIB | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 7M54K9255 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20120324 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | MSD | |
| RXA.17.2 | Text | Merck Sharp and Dohme Corp. | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20120322 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 49 | |
| RXA.5.2 | Text | Hib | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | PedvaxHIB | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 7M55K3343 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20121030 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | MSD | |
| RXA.17.2 | Text | Merck Sharp and Dohme Corp. | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20120512 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 49 | |
| RXA.5.2 | Text | Hib | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | PedvaxHIB | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 7M75K4577 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20120523 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | MSD | |
| RXA.17.2 | Text | Merck Sharp and Dohme Corp. | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20120222 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 49 | |
| RXA.5.2 | Text | Hib | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | PedvaxHIB | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 7M53K5535 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20120222 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | MSD | |
| RXA.17.2 | Text | Merck Sharp and Dohme Corp. | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20120122 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 10 | |
| RXA.5.2 | Text | Polio (IPV) | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | IPOL | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D333PV2444 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20120410 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | MSanofi Pasteur Inc. | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20120322 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 10 | |
| RXA.5.2 | Text | Polio (IPV) | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | IPOL | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D333PV4343 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20120323 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | MSanofi Pasteur Inc. | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20120521 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 10 | |
| RXA.5.2 | Text | Polio (IPV) | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | IPOL | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D333PV4343 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20120323 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | MSanofi Pasteur Inc. | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20120122 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 133 | |
| RXA.5.2 | Text | Pneumococcal conjugate (PCV13) | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | PREVNAR 13 | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | P243V3321 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20120130 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PFR | |
| RXA.17.2 | Text | Pfizer, Inc | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20120322 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 133 | |
| RXA.5.2 | Text | Pneumococcal conjugate (PCV13) | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | PREVNAR 13 | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | P343V8445 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20120330 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PFR | |
| RXA.17.2 | Text | Pfizer, Inc | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20120521 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 133 | |
| RXA.5.2 | Text | Pneumococcal conjugate (PCV13) | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | PREVNAR 13 | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | P853V2175 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20120830 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PFR | |
| RXA.17.2 | Text | Pfizer, Inc | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20121122 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 133 | |
| RXA.5.2 | Text | Pneumococcal conjugate (PCV13) | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | PREVNAR 13 | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | P853V58544 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20130118 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PFR | |
| RXA.17.2 | Text | Pfizer, Inc | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20121122 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 119 | |
| RXA.5.2 | Text | Rotavirus | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | ROTARIX | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 6359RV543 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20120215 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | SKB | |
| RXA.17.2 | Text | GlaxoSmithKline Biologicals SA | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20120322 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 119 | |
| RXA.5.2 | Text | Rotavirus | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | ROTARIX | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 6359RV933 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20120510 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | SKB | |
| RXA.17.2 | Text | GlaxoSmithKline Biologicals SA | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20120922 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 161 | |
| RXA.5.2 | Text | Influenza | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | FLUZONE QUADRIVALENT | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D8043IN8738 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20130312 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | Sanofi Pasteur | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20121022 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 161 | |
| RXA.5.2 | Text | Influenza | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | FLUZONE QUADRIVALENT | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D8043IN8798 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20130312 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | Sanofi Pasteur | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20131030 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 161 | |
| RXA.5.2 | Text | Influenza | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | FLUZONE QUADRIVALENT | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D9334IN9433 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20140522 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | Sanofi Pasteur | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20150715 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 161 | |
| RXA.5.2 | Text | Influenza | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | FLUZONE QUADRIVALENT | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 0.25 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | mL | |
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | UCUM | |
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 00 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Molina | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | Sandra | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | D8043IN8855 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20150828 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | PMC | |
| RXA.17.2 | Text | Sanofi Pasteur | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20130521 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 83 | |
| RXA.5.2 | Text | Hepatitis A | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | HAVRIX | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 6359RT35 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20140104 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | SKB | |
| RXA.17.2 | Text | GlaxoSmithKline Biologicals SA | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20131201 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 83 | |
| RXA.5.2 | Text | Hepatitis A | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | HAVRIX | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 6359RT47 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20130911 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | SKB | |
| RXA.17.2 | Text | GlaxoSmithKline Biologicals SA | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20130112 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 94 | |
| RXA.5.2 | Text | MMR and Varicella | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | ProQuad | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Martinez | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | J. | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 7W27V7632 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20161215 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | MSD | |
| RXA.17.2 | Text | Merck Sharp and Dohme Corp. | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LT | |
| RXR.2.2 | Text | Left Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | RT | |
| RXR.2.2 | Text | Right Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LT | |
| RXR.2.2 | Text | Left Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LT | |
| RXR.2.2 | Text | Left Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | RT | |
| RXR.2.2 | Text | Right Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LT | |
| RXR.2.2 | Text | Left Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | RT | |
| RXR.2.2 | Text | Right Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | SC | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | SC | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | SC | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | SC | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | SC | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | SC | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LT | |
| RXR.2.2 | Text | Left Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LT | |
| RXR.2.2 | Text | Left Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | RT | |
| RXR.2.2 | Text | Right Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LT | |
| RXR.2.2 | Text | Left Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | RT | |
| RXR.2.2 | Text | Thigh Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LT | |
| RXR.2.2 | Text | Left Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | RT | |
| RXR.2.2 | Text | Right Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | RD | |
| RXR.2.2 | Text | Right Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LD | |
| RXR.2.2 | Text | Left Deltoid | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | SC | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | SC | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LT | |
| RXR.2.2 | Text | Left Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 2 | |
| OBX.2 | Value Type | TS | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 29768-9 | |
| OBX.3.2 | Text | VIS Publication Date | |
| OBX.3.3 | Name of Coding System | LN | |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.5.1 | Time | 20120202 | |
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 3 | |
| OBX.2 | Value Type | TS | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 29769-7 | |
| OBX.3.2 | Text | VIS Presentation Date | |
| OBX.3.3 | Name of Coding System | LN | |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.5.1 | Time | 20150715 | |
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 1 | |
| OBX.2 | Value Type | CE | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 64994-7 | |
| OBX.3.2 | Text | vaccine fund pgm elig cat | |
| OBX.3.3 | Name of Coding System | LN | |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 2 | |
| OBX.2 | Value Type | TS | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 29768-9 | |
| OBX.3.2 | Text | VIS Publication Date | |
| OBX.3.3 | Name of Coding System | LN | |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.5.1 | Time | 20140819 | |
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 3 | |
| OBX.2 | Value Type | TS | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 29769-7 | |
| OBX.3.2 | Text | VIS Presentation Date | |
| OBX.3.3 | Name of Coding System | LN | |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.5.1 | Time | 20150715 | |
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 1 | |
| OBX.2 | Value Type | CE | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 64994-7 | |
| OBX.3.2 | Text | vaccine fund pgm elig cat | |
| OBX.3.3 | Name of Coding System | LN | |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Element | Data |
|---|---|
| Patient Name | Juan Marcel Gonzales |
| Mother's Maiden Name | Anita Morales |
| ID Number | 123456 987633 |
| Date/Time of Birth | 11/23/2011 |
| Administrative Sex | Male |
| Patient Address | 4623 Standish Way Stamford CT 06903 USA |
| Local Number | (203)555-1213 |
| Race | Other Race |
| Ethnic Group | Hispanic or Latino |
| Birth Order |
| Element | Data |
|---|---|
| Immunization Registry Status | A |
| Immunization Registry Status Effective Date | 07/01/2012 |
| Publicity Code | Reminder/Recall - any method |
| Publicity Code Effective Date | 07/01/2012 |
| Protection Indicator | |
| Protection Indicator Effective Date |
| Element | Data |
|---|---|
| Name | Manuel Marcel Gonzales |
| Relationship | Father |
| Address | 4623 Standish Way Stamford CT 06903 |
| Phone Number | (203)555-1213 |
| Element | Data |
|---|---|
| Administered Code | Hepatitis B |
| Date/Time Start of Administration | 11/23/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 6332FK34 |
| Substance Expiration Date | 12/14/2011 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Shoreline Hospital |
| Entered By | Lisa Sirtis |
| Ordered By | Jane Carter |
| Element | Data |
|---|---|
| Administered Code | Hepatitis B |
| Date/Time Start of Administration | 12/23/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 6352FK2 |
| Substance Expiration Date | 10/01/2011 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Hepatitis B |
| Date/Time Start of Administration | 07/15/2015 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 6332FK26 |
| Substance Expiration Date | 08/25/2015 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| VIS Publication Date | 02/02/2012 |
| VIS Presentation Date | 07/15/2015 |
| vaccine fund pgm elig cat | Not VFC elig |
| Element | Data |
|---|---|
| Administered Code | DTaP |
| Date/Time Start of Administration | 01/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D409QS2342 |
| Substance Expiration Date | 11/30/2012 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | DTaP |
| Date/Time Start of Administration | 03/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D409QS2434 |
| Substance Expiration Date | 09/04/2012 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | DTaP |
| Date/Time Start of Administration | 05/21/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D409QS250 |
| Substance Expiration Date | 01/03/2014 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | DTaP |
| Date/Time Start of Administration | 02/20/2013 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D409QS250 |
| Substance Expiration Date | 01/03/2014 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Hib |
| Date/Time Start of Administration | 01/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 7M54K9255 |
| Substance Expiration Date | 03/24/2012 |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Hib |
| Date/Time Start of Administration | 03/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 7M55K3343 |
| Substance Expiration Date | 10/30/2012 |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Hib |
| Date/Time Start of Administration | 05/12/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 7M75K4577 |
| Substance Expiration Date | 05/23/2012 |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Hib |
| Date/Time Start of Administration | 02/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 7M53K5535 |
| Substance Expiration Date | 02/22/2012 |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Polio (IPV) |
| Date/Time Start of Administration | 01/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D333PV2444 |
| Substance Expiration Date | 04/10/2012 |
| Substance Manufacturer Name | MSanofi Pasteur Inc. |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Polio (IPV) |
| Date/Time Start of Administration | 03/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D333PV4343 |
| Substance Expiration Date | 03/23/2012 |
| Substance Manufacturer Name | MSanofi Pasteur Inc. |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Polio (IPV) |
| Date/Time Start of Administration | 05/21/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D333PV4343 |
| Substance Expiration Date | 03/23/2012 |
| Substance Manufacturer Name | MSanofi Pasteur Inc. |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Pneumococcal conjugate (PCV13) |
| Date/Time Start of Administration | 01/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | P243V3321 |
| Substance Expiration Date | 01/30/2012 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Pneumococcal conjugate (PCV13) |
| Date/Time Start of Administration | 03/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | P343V8445 |
| Substance Expiration Date | 03/30/2012 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Pneumococcal conjugate (PCV13) |
| Date/Time Start of Administration | 05/21/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | P853V2175 |
| Substance Expiration Date | 08/30/2012 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Pneumococcal conjugate (PCV13) |
| Date/Time Start of Administration | 11/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | P853V58544 |
| Substance Expiration Date | 01/18/2013 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Rotavirus |
| Date/Time Start of Administration | 11/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 6359RV543 |
| Substance Expiration Date | 02/15/2012 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Rotavirus |
| Date/Time Start of Administration | 03/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 6359RV933 |
| Substance Expiration Date | 05/10/2012 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Thigh Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Influenza |
| Date/Time Start of Administration | 09/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D8043IN8738 |
| Substance Expiration Date | 03/12/2013 |
| Substance Manufacturer Name | Sanofi Pasteur |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Influenza |
| Date/Time Start of Administration | 10/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D8043IN8798 |
| Substance Expiration Date | 03/12/2013 |
| Substance Manufacturer Name | Sanofi Pasteur |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Influenza |
| Date/Time Start of Administration | 10/30/2013 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D9334IN9433 |
| Substance Expiration Date | 05/22/2014 |
| Substance Manufacturer Name | Sanofi Pasteur |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Influenza |
| Date/Time Start of Administration | 07/15/2015 |
| Administered Amount | 0.25 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | Sandra Molina |
| Substance Lot Number | D8043IN8855 |
| Substance Expiration Date | 08/28/2015 |
| Substance Manufacturer Name | Sanofi Pasteur |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| VIS Publication Date | 08/19/2014 |
| VIS Presentation Date | 07/15/2015 |
| vaccine fund pgm elig cat | Not VFC elig |
| Element | Data |
|---|---|
| Administered Code | Hepatitis A |
| Date/Time Start of Administration | 05/21/2013 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 6359RT35 |
| Substance Expiration Date | 01/04/2014 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Hepatitis A |
| Date/Time Start of Administration | 12/01/2013 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 6359RT47 |
| Substance Expiration Date | 09/11/2013 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | MMR and Varicella |
| Date/Time Start of Administration | 01/12/2013 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 7W27V7632 |
| Substance Expiration Date | 12/15/2016 |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Patient Name | Juan Marcel Gonzales |
| Mother's Maiden Name | Anita Morales |
| ID Number | 123456 987633 |
| Date/Time of Birth | 11/23/2011 |
| Administrative Sex | Male |
| Patient Address | 4623 Standish Way Stamford CT 06903 USA |
| Local Number | (203)555-1213 |
| Race | Other Race |
| Ethnic Group | Hispanic or Latino |
| Birth Order |
| Element | Data |
|---|---|
| Immunization Registry Status | A |
| Immunization Registry Status Effective Date | 07/01/2012 |
| Publicity Code | Reminder/Recall - any method |
| Publicity Code Effective Date | 07/01/2012 |
| Protection Indicator | |
| Protection Indicator Effective Date |
| Element | Data |
|---|---|
| Name | Manuel Marcel Gonzales |
| Relationship | Father |
| Address | 4623 Standish Way Stamford CT 06903 |
| Phone Number | (203)555-1213 |
| Element | Data |
|---|---|
| Administered Code | Hepatitis B |
| Date/Time Start of Administration | 11/23/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 6332FK34 |
| Substance Expiration Date | 12/14/2011 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Shoreline Hospital |
| Entered By | Lisa Sirtis |
| Ordered By | Jane Carter |
| Element | Data |
|---|---|
| Administered Code | Hepatitis B |
| Date/Time Start of Administration | 12/23/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 6352FK2 |
| Substance Expiration Date | 10/01/2011 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Hepatitis B |
| Date/Time Start of Administration | 07/15/2015 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 6332FK26 |
| Substance Expiration Date | 08/25/2015 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| VIS Publication Date | 02/02/2012 |
| VIS Presentation Date | 07/15/2015 |
| vaccine fund pgm elig cat | Not VFC elig |
| Element | Data |
|---|---|
| Administered Code | DTaP |
| Date/Time Start of Administration | 01/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D409QS2342 |
| Substance Expiration Date | 11/30/2012 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | DTaP |
| Date/Time Start of Administration | 03/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D409QS2434 |
| Substance Expiration Date | 09/04/2012 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | DTaP |
| Date/Time Start of Administration | 05/21/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D409QS250 |
| Substance Expiration Date | 01/03/2014 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | DTaP |
| Date/Time Start of Administration | 02/20/2013 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D409QS250 |
| Substance Expiration Date | 01/03/2014 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Hib |
| Date/Time Start of Administration | 01/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 7M54K9255 |
| Substance Expiration Date | 03/24/2012 |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Hib |
| Date/Time Start of Administration | 03/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 7M55K3343 |
| Substance Expiration Date | 10/30/2012 |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Hib |
| Date/Time Start of Administration | 05/12/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 7M75K4577 |
| Substance Expiration Date | 05/23/2012 |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Hib |
| Date/Time Start of Administration | 02/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 7M53K5535 |
| Substance Expiration Date | 02/22/2012 |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Polio (IPV) |
| Date/Time Start of Administration | 01/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D333PV2444 |
| Substance Expiration Date | 04/10/2012 |
| Substance Manufacturer Name | MSanofi Pasteur Inc. |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Polio (IPV) |
| Date/Time Start of Administration | 03/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D333PV4343 |
| Substance Expiration Date | 03/23/2012 |
| Substance Manufacturer Name | MSanofi Pasteur Inc. |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Polio (IPV) |
| Date/Time Start of Administration | 05/21/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D333PV4343 |
| Substance Expiration Date | 03/23/2012 |
| Substance Manufacturer Name | MSanofi Pasteur Inc. |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Pneumococcal conjugate (PCV13) |
| Date/Time Start of Administration | 01/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | P243V3321 |
| Substance Expiration Date | 01/30/2012 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Pneumococcal conjugate (PCV13) |
| Date/Time Start of Administration | 03/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | P343V8445 |
| Substance Expiration Date | 03/30/2012 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Pneumococcal conjugate (PCV13) |
| Date/Time Start of Administration | 05/21/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | P853V2175 |
| Substance Expiration Date | 08/30/2012 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Pneumococcal conjugate (PCV13) |
| Date/Time Start of Administration | 11/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | P853V58544 |
| Substance Expiration Date | 01/18/2013 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Rotavirus |
| Date/Time Start of Administration | 11/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 6359RV543 |
| Substance Expiration Date | 02/15/2012 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Rotavirus |
| Date/Time Start of Administration | 03/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 6359RV933 |
| Substance Expiration Date | 05/10/2012 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Thigh Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Influenza |
| Date/Time Start of Administration | 09/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D8043IN8738 |
| Substance Expiration Date | 03/12/2013 |
| Substance Manufacturer Name | Sanofi Pasteur |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Influenza |
| Date/Time Start of Administration | 10/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D8043IN8798 |
| Substance Expiration Date | 03/12/2013 |
| Substance Manufacturer Name | Sanofi Pasteur |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Influenza |
| Date/Time Start of Administration | 10/30/2013 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D9334IN9433 |
| Substance Expiration Date | 05/22/2014 |
| Substance Manufacturer Name | Sanofi Pasteur |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Influenza |
| Date/Time Start of Administration | 07/15/2015 |
| Administered Amount | 0.25 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | Sandra Molina |
| Substance Lot Number | D8043IN8855 |
| Substance Expiration Date | 08/28/2015 |
| Substance Manufacturer Name | Sanofi Pasteur |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| VIS Publication Date | 08/19/2014 |
| VIS Presentation Date | 07/15/2015 |
| vaccine fund pgm elig cat | Not VFC elig |
| Element | Data |
|---|---|
| Administered Code | Hepatitis A |
| Date/Time Start of Administration | 05/21/2013 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 6359RT35 |
| Substance Expiration Date | 01/04/2014 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Hepatitis A |
| Date/Time Start of Administration | 12/01/2013 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 6359RT47 |
| Substance Expiration Date | 09/11/2013 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | MMR and Varicella |
| Date/Time Start of Administration | 01/12/2013 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 7W27V7632 |
| Substance Expiration Date | 12/15/2016 |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| No Description |
| No Comments |
| No PreCondition |
| No PostCondition |
| No Test Objectives |
| No evaluation criteria |
| No Note |
Following the visit, the EMR transmits an Immunization report to the Immunization Registry using the VXU/Z22. The Vaccination report includes the vaccine deferrals. The report MAY send the immunizations that the EMR imported from the IIS. |
The Report must include all vaccine deferrals recorded in the EMR in any order. The report may include the information imported from the IIS |
The vaccines for the visit have been administered. |
The Immunization Report has been transmitted to the IIS using a valid Z22 VXU in accordance with the test data correctly and without omission. |
Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries. |
The VXU/Z22 message passes validation using the NIST Immunization VXU Validation Tool (Z22) (context-free). The content of the message correctly reflects the test data (context-based) in accordance with the Test Data Specification and the Message Content. The message must contain all deferrals recorded in the EMR. Current Date is expected for the Non-Administration date and deferral date. |
No Note |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| MSH.1 | Field Separator | | | |
| MSH.2 | Encoding Characters | ^~\& | |
| MSH.3 | Sending Application | ||
| MSH.3.1 | Namespace ID | Test EHR Application | |
| MSH.3.2 | Universal ID | ||
| MSH.3.3 | Universal ID Type | ||
| MSH.4 | Sending Facility | ||
| MSH.4.1 | Namespace ID | X68 | |
| MSH.4.2 | Universal ID | ||
| MSH.4.3 | Universal ID Type | ||
| MSH.5 | Receiving Application | ||
| MSH.5.1 | Namespace ID | ||
| MSH.5.2 | Universal ID | ||
| MSH.5.3 | Universal ID Type | ||
| MSH.6 | Receiving Facility | ||
| MSH.6.1 | Namespace ID | NIST Test Iz Reg | |
| MSH.6.2 | Universal ID | ||
| MSH.6.3 | Universal ID Type | ||
| MSH.7 | Date/Time Of Message | ||
| MSH.7.1 | Time | 20120701082240-0500 | |
| MSH.9 | Message Type | ||
| MSH.9.1 | Message Code | VXU | |
| MSH.9.2 | Trigger Event | V04 | |
| MSH.9.3 | Message Structure | VXU_V04 | |
| MSH.10 | Message Control ID | NIST-IZ-001.00 | |
| MSH.11 | Processing ID | ||
| MSH.11.1 | Processing ID | P | |
| MSH.12 | Version ID | ||
| MSH.12.1 | Version ID | 2.5.1 | |
| MSH.15 | Accept Acknowledgment Type | ER | |
| MSH.16 | Application Acknowledgment Type | AL | |
| MSH.21 | Message Profile Identifier | ||
| MSH.21.1 | Entity Identifier | Z22 | |
| MSH.21.2 | Namespace ID | CDCPHINVS | |
| MSH.21.3 | Universal ID | ||
| MSH.21.4 | Universal ID Type | ||
| MSH.22 | Sending Responsible Organization | ||
| MSH.22.1 | Organization Name | ||
| MSH.22.6 | Assigning Authority | ||
| MSH.22.6.1 | Namespace ID | ||
| MSH.22.6.2 | Universal ID | ||
| MSH.22.6.3 | Universal ID Type | ||
| MSH.22.7 | Identifier Type Code | ||
| MSH.22.10 | Organization Identifier | ||
| MSH.23 | Receiving Responsible Organization | ||
| MSH.23.1 | Organization Name | ||
| MSH.23.6 | Assigning Authority | ||
| MSH.23.6.1 | Namespace ID | ||
| MSH.23.6.2 | Universal ID | ||
| MSH.23.6.3 | Universal ID Type | ||
| MSH.23.7 | Identifier Type Code | ||
| MSH.23.10 | Organization Identifier |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| PID.1 | Set ID - PID | 1 | |
| PID.3 | Patient Identifier List | ||
| PID.3.1 | ID Number | 123456 | |
| PID.3.3 | Check Digit Scheme | ||
| PID.3.4 | Assigning Authority | ||
| PID.3.4.1 | Namespace ID | MYEHR | |
| PID.3.4.2 | Universal ID | ||
| PID.3.4.3 | Universal ID Type | ||
| PID.3.5 | Identifier Type Code | MR | |
| PID.3 | Patient Identifier List | ||
| PID.3.1 | ID Number | 987633 | |
| PID.3.3 | Check Digit Scheme | ||
| PID.3.4 | Assigning Authority | ||
| PID.3.4.1 | Namespace ID | MYIIS | |
| PID.3.4.2 | Universal ID | ||
| PID.3.4.3 | Universal ID Type | ||
| PID.3.5 | Identifier Type Code | SR | |
| PID.5 | Patient Name | ||
| PID.5.1 | Family Name | ||
| PID.5.1.1 | Surname | Morales | |
| PID.5.1.2 | Own Surname Prefix | ||
| PID.5.1.3 | Own Surname | ||
| PID.5.1.4 | Surname Prefix From Partner/Spouse | ||
| PID.5.1.5 | Surname From Partner/Spouse | ||
| PID.5.2 | Given Name | Mariela | Test Case Fixed |
| PID.5.3 | Second and Further Given Names or Initials Thereof | Gonzales | Test Case Fixed |
| PID.5.7 | Name Type Code | L | Test Case Fixed |
| PID.6 | Mother's Maiden Name | ||
| PID.6.1 | Family Name | ||
| PID.6.1.1 | Surname | Gonzales | Test Case Fixed |
| PID.6.1.2 | Own Surname Prefix | ||
| PID.6.1.3 | Own Surname | ||
| PID.6.1.4 | Surname Prefix From Partner/Spouse | ||
| PID.6.1.5 | Surname From Partner/Spouse | ||
| PID.6.7 | Name Type Code | M | Test Case Fixed |
| PID.7 | Date/Time of Birth | ||
| PID.7.1 | Time | 201503301115 | Test Case Fixed |
| PID.8 | Administrative Sex | F | Test Case Fixed |
| PID.10 | Race | ||
| PID.10.1 | Identifier | 2131-1 | Test Case Fixed |
| PID.10.2 | Text | Other Race | Test Case Fixed |
| PID.10.3 | Name of Coding System | HL70005 | Test Case Fixed |
| PID.10.5 | Alternate Text | ||
| PID.10.6 | Name of Alternate Coding System | ||
| PID.11 | Patient Address | ||
| PID.11.1 | Street Address | ||
| PID.11.1.1 | Street or Mailing Address | 3321 Standish Way | Test Case Fixed |
| PID.11.1.2 | Street Name | ||
| PID.11.1.3 | Dwelling Number | ||
| PID.11.2 | Other Designation | ||
| PID.11.3 | City | Stamford | Test Case Fixed |
| PID.11.4 | State or Province | CT | Test Case Fixed |
| PID.11.5 | Zip or Postal Code | 06903 | Test Case Fixed |
| PID.11.6 | Country | USA | Test Case Fixed |
| PID.11.7 | Address Type | L | Test Case Fixed |
| PID.11 | Patient Address | ||
| PID.11.1 | Street Address | ||
| PID.11.1.1 | Street or Mailing Address | 325 Shorline Drive | |
| PID.11.1.2 | Street Name | ||
| PID.11.1.3 | Dwelling Number | ||
| PID.11.2 | Other Designation | ||
| PID.11.3 | City | Stamford | |
| PID.11.4 | State or Province | CT | Test Case Fixed |
| PID.11.5 | Zip or Postal Code | 06901 | |
| PID.11.6 | Country | ||
| PID.11.7 | Address Type | BDL | Test Case Fixed |
| PID.13 | Phone Number - Home | ||
| PID.13.2 | Telecommunication Use Code | PRN | Test Case Fixed |
| PID.13.3 | Telecommunication Equipment Type | PH | Test Case Fixed |
| PID.13.4 | Email Address | ||
| PID.13.6 | Area/City Code | 203 | Test Case Fixed |
| PID.13.7 | Local Number | 5551214 | Test Case Fixed |
| PID.22 | Ethnic Group | ||
| PID.22.1 | Identifier | 2135-2 | Test Case Fixed |
| PID.22.2 | Text | Hispanic or Latino | Test Case Fixed |
| PID.22.3 | Name of Coding System | CDCREC | Test Case Fixed |
| PID.22.5 | Alternate Text | ||
| PID.22.6 | Name of Alternate Coding System | ||
| PID.24 | Multiple Birth Indicator | ||
| PID.25 | Birth Order | ||
| PID.29 | Patient Death Date and Time | ||
| PID.29.1 | Time | ||
| PID.30 | Patient Death Indicator |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| PD1.11 | Publicity Code | ||
| PD1.11.1 | Identifier | 02 | |
| PD1.11.2 | Text | Reminder/Recall - any method | |
| PD1.11.3 | Name of Coding System | HL70215 | |
| PD1.11.5 | Alternate Text | ||
| PD1.11.6 | Name of Alternate Coding System | ||
| PD1.12 | Protection Indicator | ||
| PD1.13 | Protection Indicator Effective Date | ||
| PD1.16 | Immunization Registry Status | A | |
| PD1.17 | Immunization Registry Status Effective Date | 20120701 | |
| PD1.18 | Publicity Code Effective Date | 20120701 |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| NK1.1 | Set ID - NK1 | 1 | |
| NK1.2 | Name | ||
| NK1.2.1 | Family Name | ||
| NK1.2.1.1 | Surname | Morales | Test Case Fixed |
| NK1.2.1.2 | Own Surname Prefix | ||
| NK1.2.1.3 | Own Surname | ||
| NK1.2.1.4 | Surname Prefix From Partner/Spouse | ||
| NK1.2.1.5 | Surname From Partner/Spouse | ||
| NK1.2.2 | Given Name | Joanna | Test Case Fixed |
| NK1.2.3 | Second and Further Given Names or Initials Thereof | Gonzales | Test Case Fixed |
| NK1.2.7 | Name Type Code | L | Test Case Fixed |
| NK1.3 | Relationship | ||
| NK1.3.1 | Identifier | MTH | Test Case Fixed |
| NK1.3.2 | Text | Mother | Test Case Fixed |
| NK1.3.3 | Name of Coding System | HL70063 | |
| NK1.3.5 | Alternate Text | ||
| NK1.3.6 | Name of Alternate Coding System | ||
| NK1.4 | Address | ||
| NK1.4.1 | Street Address | ||
| NK1.4.1.1 | Street or Mailing Address | 4623 Standish Way | Test Case Fixed |
| NK1.4.1.2 | Street Name | ||
| NK1.4.1.3 | Dwelling Number | ||
| NK1.4.2 | Other Designation | ||
| NK1.4.3 | City | Stamford | Test Case Fixed |
| NK1.4.4 | State or Province | CT | Test Case Fixed |
| NK1.4.5 | Zip or Postal Code | 06903 | Test Case Fixed |
| NK1.4.6 | Country | ||
| NK1.4.7 | Address Type | L | Test Case Fixed |
| NK1.5 | Phone Number | ||
| NK1.5.2 | Telecommunication Use Code | PRN | Test Case Fixed |
| NK1.5.3 | Telecommunication Equipment Type | PH | Test Case Fixed |
| NK1.5.4 | Email Address | ||
| NK1.5.6 | Area/City Code | 203 | Test Case Fixed |
| NK1.5.7 | Local Number | 5551213 | Test Case Fixed |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Sirtis | Test Case Fixed |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | Lisa | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Carter | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Jane | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | SH | |
| ORC.17.2 | Text | Shoreline Hospital | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 9999 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Molina | Test Case Fixed |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | Sandra | Test Case Fixed |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Smith | Test Case Fixed |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Frank | Test Case Fixed |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | Test Case Fixed |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | SP | |
| ORC.17.2 | Text | Shoreline Pediatrics | Test Case Fixed |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 9999 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Molina | Test Case Fixed |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | Sandra | Test Case Fixed |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Smith | Test Case Fixed |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Frank | Test Case Fixed |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | SP | |
| ORC.17.2 | Text | Shoreline Pediatrics | Test Case Fixed |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 9999 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Molina | Test Case Fixed |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | Sandra | Test Case Fixed |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Smith | Test Case Fixed |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Frank | Test Case Fixed |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | Test Case Fixed |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | SP | |
| ORC.17.2 | Text | Shoreline Pediatrics | Test Case Fixed |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 9999 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Molina | Test Case Fixed |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | Sandra | Test Case Fixed |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Smith | Test Case Fixed |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Frank | Test Case Fixed |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | Test Case Fixed |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | SP | |
| ORC.17.2 | Text | Shoreline Pediatrics | Test Case Fixed |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 9999 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Molina | Test Case Fixed |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | Sandra | Test Case Fixed |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Smith | Test Case Fixed |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Frank | Test Case Fixed |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | SP | |
| ORC.17.2 | Text | Shoreline Pediatrics | Test Case Fixed |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20091123 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 08 | |
| RXA.5.2 | Text | hepatitis B vaccine, pediatric or pediatric/adolescent dosage | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | ENGERIX-B | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Sirtis | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | Lisa | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 6332FK33 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20101214 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | SKB | |
| RXA.17.2 | Text | GlaxoSmithKline Biologicals SA | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20150715 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 45 | Test Case Fixed |
| RXA.5.2 | Text | hepatitis B vaccine, unspecified formulation | Test Case Fixed |
| RXA.5.3 | Name of Coding System | CVX | Test Case Fixed |
| RXA.5.5 | Alternate Text | ||
| RXA.5.6 | Name of Alternate Coding System | ||
| RXA.6 | Administered Amount | 999 | Test Case Fixed |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | ||
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | ||
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | ||
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | ||
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | ||
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | ||
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | ||
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | ||
| RXA.17.2 | Text | ||
| RXA.17.3 | Name of Coding System | ||
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | NA | Test Case Fixed |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20150715 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 107 | Test Case Fixed |
| RXA.5.2 | Text | DTaP, unspecified formulation | Test Case Fixed |
| RXA.5.3 | Name of Coding System | CVX | Test Case Fixed |
| RXA.5.5 | Alternate Text | ||
| RXA.5.6 | Name of Alternate Coding System | ||
| RXA.6 | Administered Amount | 999 | Test Case Fixed |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | ||
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | ||
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | ||
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | ||
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | ||
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | ||
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | ||
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | ||
| RXA.17.2 | Text | ||
| RXA.17.3 | Name of Coding System | ||
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | NA | Test Case Fixed |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20150715 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 08 | Test Case Fixed |
| RXA.5.2 | Text | Hib | Test Case Fixed |
| RXA.5.3 | Name of Coding System | CVX | Test Case Fixed |
| RXA.5.5 | Alternate Text | ||
| RXA.5.6 | Name of Alternate Coding System | ||
| RXA.6 | Administered Amount | 999 | Test Case Fixed |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | ||
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | ||
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | ||
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | ||
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | ||
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | ||
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | ||
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | ||
| RXA.17.2 | Text | ||
| RXA.17.3 | Name of Coding System | ||
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | NA | Test Case Fixed |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20150715 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 152 | Test Case Fixed |
| RXA.5.2 | Text | Pneumococcal Conjugate, unspecified formulation | Test Case Fixed |
| RXA.5.3 | Name of Coding System | CVX | Test Case Fixed |
| RXA.5.5 | Alternate Text | ||
| RXA.5.6 | Name of Alternate Coding System | ||
| RXA.6 | Administered Amount | 999 | Test Case Fixed |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | ||
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | ||
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | ||
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | ||
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | ||
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | ||
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | ||
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | ||
| RXA.17.2 | Text | ||
| RXA.17.3 | Name of Coding System | ||
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | NA | Test Case Fixed |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20150715 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 122 | Test Case Fixed |
| RXA.5.2 | Text | rotavirus, unspecified formulation | Test Case Fixed |
| RXA.5.3 | Name of Coding System | CVX | Test Case Fixed |
| RXA.5.5 | Alternate Text | ||
| RXA.5.6 | Name of Alternate Coding System | ||
| RXA.6 | Administered Amount | 999 | Test Case Fixed |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | ||
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | ||
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | ||
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | ||
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | ||
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | ||
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | ||
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | ||
| RXA.17.2 | Text | ||
| RXA.17.3 | Name of Coding System | ||
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | NA | Test Case Fixed |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LT | |
| RXR.2.2 | Text | Left Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 1 | |
| OBX.2 | Value Type | CE | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 30945-0 | Test Case Fixed |
| OBX.3.2 | Text | Vaccination contraindication | Test Case Fixed |
| OBX.3.3 | Name of Coding System | LN | Test Case Fixed |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 2 | |
| OBX.2 | Value Type | TS | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 30946-8 | Test Case Fixed |
| OBX.3.2 | Text | Vaccination contraindication/precaution effective date | Test Case Fixed |
| OBX.3.3 | Name of Coding System | LN | Test Case Fixed |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.5.1 | Time | 20150715 | |
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 3 | |
| OBX.2 | Value Type | TS | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 30944-3 | Test Case Fixed |
| OBX.3.2 | Text | Vaccination temporary contraindication/precaution expiration date | Test Case Fixed |
| OBX.3.3 | Name of Coding System | LN | Test Case Fixed |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.5.1 | Time | 20150815 | |
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 1 | |
| OBX.2 | Value Type | CE | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 30945-0 | Test Case Fixed |
| OBX.3.2 | Text | Vaccination contraindication | Test Case Fixed |
| OBX.3.3 | Name of Coding System | LN | Test Case Fixed |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 2 | |
| OBX.2 | Value Type | TS | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 30946-8 | Test Case Fixed |
| OBX.3.2 | Text | Vaccination contraindication/precaution effective date | Test Case Fixed |
| OBX.3.3 | Name of Coding System | LN | Test Case Fixed |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.5.1 | Time | 20150715 | |
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 3 | |
| OBX.2 | Value Type | TS | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 30944-3 | Test Case Fixed |
| OBX.3.2 | Text | Vaccination temporary contraindication/precaution expiration date | Test Case Fixed |
| OBX.3.3 | Name of Coding System | LN | Test Case Fixed |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.5.1 | Time | 20150815 | |
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 1 | |
| OBX.2 | Value Type | CE | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 30945-0 | Test Case Fixed |
| OBX.3.2 | Text | Vaccination contraindication | Test Case Fixed |
| OBX.3.3 | Name of Coding System | LN | Test Case Fixed |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 2 | |
| OBX.2 | Value Type | TS | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 30946-8 | Test Case Fixed |
| OBX.3.2 | Text | Vaccination contraindication/precaution effective date | Test Case Fixed |
| OBX.3.3 | Name of Coding System | LN | Test Case Fixed |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.5.1 | Time | 20150715 | |
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 3 | |
| OBX.2 | Value Type | TS | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 30944-3 | Test Case Fixed |
| OBX.3.2 | Text | Vaccination temporary contraindication/precaution expiration date | Test Case Fixed |
| OBX.3.3 | Name of Coding System | LN | Test Case Fixed |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.5.1 | Time | 20150815 | |
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 1 | |
| OBX.2 | Value Type | CE | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 30945-0 | Test Case Fixed |
| OBX.3.2 | Text | Vaccination contraindication | Test Case Fixed |
| OBX.3.3 | Name of Coding System | LN | Test Case Fixed |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 2 | |
| OBX.2 | Value Type | TS | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 30946-8 | Test Case Fixed |
| OBX.3.2 | Text | Vaccination contraindication/precaution effective date | Test Case Fixed |
| OBX.3.3 | Name of Coding System | LN | Test Case Fixed |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.5.1 | Time | 20150715 | |
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 3 | |
| OBX.2 | Value Type | TS | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 30944-3 | Test Case Fixed |
| OBX.3.2 | Text | Vaccination temporary contraindication/precaution expiration date | Test Case Fixed |
| OBX.3.3 | Name of Coding System | LN | Test Case Fixed |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.5.1 | Time | 20150815 | |
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 1 | |
| OBX.2 | Value Type | CE | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 30945-0 | Test Case Fixed |
| OBX.3.2 | Text | Vaccination contraindication | Test Case Fixed |
| OBX.3.3 | Name of Coding System | LN | Test Case Fixed |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 2 | |
| OBX.2 | Value Type | TS | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 30946-8 | Test Case Fixed |
| OBX.3.2 | Text | Vaccination contraindication/precaution effective date | Test Case Fixed |
| OBX.3.3 | Name of Coding System | LN | Test Case Fixed |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.5.1 | Time | 20150715 | |
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 3 | |
| OBX.2 | Value Type | TS | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 30944-3 | Test Case Fixed |
| OBX.3.2 | Text | Vaccination temporary contraindication/precaution expiration date | Test Case Fixed |
| OBX.3.3 | Name of Coding System | LN | Test Case Fixed |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.5.1 | Time | 20150815 | |
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| MSH.1 | Field Separator | | | |
| MSH.2 | Encoding Characters | ^~\& | |
| MSH.3 | Sending Application | ||
| MSH.3.1 | Namespace ID | Test EHR Application | |
| MSH.3.2 | Universal ID | ||
| MSH.3.3 | Universal ID Type | ||
| MSH.4 | Sending Facility | ||
| MSH.4.1 | Namespace ID | X68 | |
| MSH.4.2 | Universal ID | ||
| MSH.4.3 | Universal ID Type | ||
| MSH.5 | Receiving Application | ||
| MSH.5.1 | Namespace ID | ||
| MSH.5.2 | Universal ID | ||
| MSH.5.3 | Universal ID Type | ||
| MSH.6 | Receiving Facility | ||
| MSH.6.1 | Namespace ID | NIST Test Iz Reg | |
| MSH.6.2 | Universal ID | ||
| MSH.6.3 | Universal ID Type | ||
| MSH.7 | Date/Time Of Message | ||
| MSH.7.1 | Time | 20120701082240-0500 | |
| MSH.9 | Message Type | ||
| MSH.9.1 | Message Code | VXU | |
| MSH.9.2 | Trigger Event | V04 | |
| MSH.9.3 | Message Structure | VXU_V04 | |
| MSH.10 | Message Control ID | NIST-IZ-001.00 | |
| MSH.11 | Processing ID | ||
| MSH.11.1 | Processing ID | P | |
| MSH.12 | Version ID | ||
| MSH.12.1 | Version ID | 2.5.1 | |
| MSH.15 | Accept Acknowledgment Type | ER | |
| MSH.16 | Application Acknowledgment Type | AL | |
| MSH.21 | Message Profile Identifier | ||
| MSH.21.1 | Entity Identifier | Z22 | |
| MSH.21.2 | Namespace ID | CDCPHINVS | |
| MSH.21.3 | Universal ID | ||
| MSH.21.4 | Universal ID Type | ||
| MSH.22 | Sending Responsible Organization | ||
| MSH.22.1 | Organization Name | ||
| MSH.22.6 | Assigning Authority | ||
| MSH.22.6.1 | Namespace ID | ||
| MSH.22.6.2 | Universal ID | ||
| MSH.22.6.3 | Universal ID Type | ||
| MSH.22.7 | Identifier Type Code | ||
| MSH.22.10 | Organization Identifier | ||
| MSH.23 | Receiving Responsible Organization | ||
| MSH.23.1 | Organization Name | ||
| MSH.23.6 | Assigning Authority | ||
| MSH.23.6.1 | Namespace ID | ||
| MSH.23.6.2 | Universal ID | ||
| MSH.23.6.3 | Universal ID Type | ||
| MSH.23.7 | Identifier Type Code | ||
| MSH.23.10 | Organization Identifier |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| PID.1 | Set ID - PID | 1 | |
| PID.3 | Patient Identifier List | ||
| PID.3.1 | ID Number | 123456 | |
| PID.3.3 | Check Digit Scheme | ||
| PID.3.4 | Assigning Authority | ||
| PID.3.4.1 | Namespace ID | MYEHR | |
| PID.3.4.2 | Universal ID | ||
| PID.3.4.3 | Universal ID Type | ||
| PID.3.5 | Identifier Type Code | MR | |
| PID.3 | Patient Identifier List | ||
| PID.3.1 | ID Number | 987633 | |
| PID.3.3 | Check Digit Scheme | ||
| PID.3.4 | Assigning Authority | ||
| PID.3.4.1 | Namespace ID | MYIIS | |
| PID.3.4.2 | Universal ID | ||
| PID.3.4.3 | Universal ID Type | ||
| PID.3.5 | Identifier Type Code | SR | |
| PID.5 | Patient Name | ||
| PID.5.1 | Family Name | ||
| PID.5.1.1 | Surname | Morales | |
| PID.5.1.2 | Own Surname Prefix | ||
| PID.5.1.3 | Own Surname | ||
| PID.5.1.4 | Surname Prefix From Partner/Spouse | ||
| PID.5.1.5 | Surname From Partner/Spouse | ||
| PID.5.2 | Given Name | Mariela | Test Case Fixed |
| PID.5.3 | Second and Further Given Names or Initials Thereof | Gonzales | Test Case Fixed |
| PID.5.7 | Name Type Code | L | Test Case Fixed |
| PID.6 | Mother's Maiden Name | ||
| PID.6.1 | Family Name | ||
| PID.6.1.1 | Surname | Gonzales | Test Case Fixed |
| PID.6.1.2 | Own Surname Prefix | ||
| PID.6.1.3 | Own Surname | ||
| PID.6.1.4 | Surname Prefix From Partner/Spouse | ||
| PID.6.1.5 | Surname From Partner/Spouse | ||
| PID.6.7 | Name Type Code | M | Test Case Fixed |
| PID.7 | Date/Time of Birth | ||
| PID.7.1 | Time | 201503301115 | Test Case Fixed |
| PID.8 | Administrative Sex | F | Test Case Fixed |
| PID.10 | Race | ||
| PID.10.1 | Identifier | 2131-1 | Test Case Fixed |
| PID.10.2 | Text | Other Race | Test Case Fixed |
| PID.10.3 | Name of Coding System | HL70005 | Test Case Fixed |
| PID.10.5 | Alternate Text | ||
| PID.10.6 | Name of Alternate Coding System | ||
| PID.11 | Patient Address | ||
| PID.11.1 | Street Address | ||
| PID.11.1.1 | Street or Mailing Address | 3321 Standish Way | Test Case Fixed |
| PID.11.1.2 | Street Name | ||
| PID.11.1.3 | Dwelling Number | ||
| PID.11.2 | Other Designation | ||
| PID.11.3 | City | Stamford | Test Case Fixed |
| PID.11.4 | State or Province | CT | Test Case Fixed |
| PID.11.5 | Zip or Postal Code | 06903 | Test Case Fixed |
| PID.11.6 | Country | USA | Test Case Fixed |
| PID.11.7 | Address Type | L | Test Case Fixed |
| PID.11 | Patient Address | ||
| PID.11.1 | Street Address | ||
| PID.11.1.1 | Street or Mailing Address | 325 Shorline Drive | |
| PID.11.1.2 | Street Name | ||
| PID.11.1.3 | Dwelling Number | ||
| PID.11.2 | Other Designation | ||
| PID.11.3 | City | Stamford | |
| PID.11.4 | State or Province | CT | Test Case Fixed |
| PID.11.5 | Zip or Postal Code | 06901 | |
| PID.11.6 | Country | ||
| PID.11.7 | Address Type | BDL | Test Case Fixed |
| PID.13 | Phone Number - Home | ||
| PID.13.2 | Telecommunication Use Code | PRN | Test Case Fixed |
| PID.13.3 | Telecommunication Equipment Type | PH | Test Case Fixed |
| PID.13.4 | Email Address | ||
| PID.13.6 | Area/City Code | 203 | Test Case Fixed |
| PID.13.7 | Local Number | 5551214 | Test Case Fixed |
| PID.22 | Ethnic Group | ||
| PID.22.1 | Identifier | 2135-2 | Test Case Fixed |
| PID.22.2 | Text | Hispanic or Latino | Test Case Fixed |
| PID.22.3 | Name of Coding System | CDCREC | Test Case Fixed |
| PID.22.5 | Alternate Text | ||
| PID.22.6 | Name of Alternate Coding System | ||
| PID.24 | Multiple Birth Indicator | ||
| PID.25 | Birth Order | ||
| PID.29 | Patient Death Date and Time | ||
| PID.29.1 | Time | ||
| PID.30 | Patient Death Indicator |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| PD1.11 | Publicity Code | ||
| PD1.11.1 | Identifier | 02 | |
| PD1.11.2 | Text | Reminder/Recall - any method | |
| PD1.11.3 | Name of Coding System | HL70215 | |
| PD1.11.5 | Alternate Text | ||
| PD1.11.6 | Name of Alternate Coding System | ||
| PD1.12 | Protection Indicator | ||
| PD1.13 | Protection Indicator Effective Date | ||
| PD1.16 | Immunization Registry Status | A | |
| PD1.17 | Immunization Registry Status Effective Date | 20120701 | |
| PD1.18 | Publicity Code Effective Date | 20120701 |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| NK1.1 | Set ID - NK1 | 1 | |
| NK1.2 | Name | ||
| NK1.2.1 | Family Name | ||
| NK1.2.1.1 | Surname | Morales | Test Case Fixed |
| NK1.2.1.2 | Own Surname Prefix | ||
| NK1.2.1.3 | Own Surname | ||
| NK1.2.1.4 | Surname Prefix From Partner/Spouse | ||
| NK1.2.1.5 | Surname From Partner/Spouse | ||
| NK1.2.2 | Given Name | Joanna | Test Case Fixed |
| NK1.2.3 | Second and Further Given Names or Initials Thereof | Gonzales | Test Case Fixed |
| NK1.2.7 | Name Type Code | L | Test Case Fixed |
| NK1.3 | Relationship | ||
| NK1.3.1 | Identifier | MTH | Test Case Fixed |
| NK1.3.2 | Text | Mother | Test Case Fixed |
| NK1.3.3 | Name of Coding System | HL70063 | |
| NK1.3.5 | Alternate Text | ||
| NK1.3.6 | Name of Alternate Coding System | ||
| NK1.4 | Address | ||
| NK1.4.1 | Street Address | ||
| NK1.4.1.1 | Street or Mailing Address | 4623 Standish Way | Test Case Fixed |
| NK1.4.1.2 | Street Name | ||
| NK1.4.1.3 | Dwelling Number | ||
| NK1.4.2 | Other Designation | ||
| NK1.4.3 | City | Stamford | Test Case Fixed |
| NK1.4.4 | State or Province | CT | Test Case Fixed |
| NK1.4.5 | Zip or Postal Code | 06903 | Test Case Fixed |
| NK1.4.6 | Country | ||
| NK1.4.7 | Address Type | L | Test Case Fixed |
| NK1.5 | Phone Number | ||
| NK1.5.2 | Telecommunication Use Code | PRN | Test Case Fixed |
| NK1.5.3 | Telecommunication Equipment Type | PH | Test Case Fixed |
| NK1.5.4 | Email Address | ||
| NK1.5.6 | Area/City Code | 203 | Test Case Fixed |
| NK1.5.7 | Local Number | 5551213 | Test Case Fixed |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 197027 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Sirtis | Test Case Fixed |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | Lisa | |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Carter | |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Jane | |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | SH | |
| ORC.17.2 | Text | Shoreline Hospital | |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 9999 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Molina | Test Case Fixed |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | Sandra | Test Case Fixed |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Smith | Test Case Fixed |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Frank | Test Case Fixed |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | Test Case Fixed |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | SP | |
| ORC.17.2 | Text | Shoreline Pediatrics | Test Case Fixed |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 9999 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Molina | Test Case Fixed |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | Sandra | Test Case Fixed |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Smith | Test Case Fixed |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Frank | Test Case Fixed |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | SP | |
| ORC.17.2 | Text | Shoreline Pediatrics | Test Case Fixed |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 9999 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Molina | Test Case Fixed |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | Sandra | Test Case Fixed |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Smith | Test Case Fixed |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Frank | Test Case Fixed |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | Test Case Fixed |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | SP | |
| ORC.17.2 | Text | Shoreline Pediatrics | Test Case Fixed |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 9999 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Molina | Test Case Fixed |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | Sandra | Test Case Fixed |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Smith | Test Case Fixed |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Frank | Test Case Fixed |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | Test Case Fixed |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | SP | |
| ORC.17.2 | Text | Shoreline Pediatrics | Test Case Fixed |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| ORC.1 | Order Control | RE | |
| ORC.2 | Placer Order Number | ||
| ORC.2.1 | Entity Identifier | ||
| ORC.2.2 | Namespace ID | ||
| ORC.2.3 | Universal ID | ||
| ORC.2.4 | Universal ID Type | ||
| ORC.3 | Filler Order Number | ||
| ORC.3.1 | Entity Identifier | 9999 | |
| ORC.3.2 | Namespace ID | DCS | |
| ORC.3.3 | Universal ID | ||
| ORC.3.4 | Universal ID Type | ||
| ORC.10 | Entered By | ||
| ORC.10.1 | ID Number | ||
| ORC.10.2 | Family Name | ||
| ORC.10.2.1 | Surname | Molina | Test Case Fixed |
| ORC.10.2.2 | Own Surname Prefix | ||
| ORC.10.2.3 | Own Surname | ||
| ORC.10.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.10.2.5 | Surname From Partner/Spouse | ||
| ORC.10.3 | Given Name | Sandra | Test Case Fixed |
| ORC.10.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.10.9 | Assigning Authority | ||
| ORC.10.9.1 | Namespace ID | ||
| ORC.10.9.2 | Universal ID | ||
| ORC.10.9.3 | Universal ID Type | ||
| ORC.10.10 | Name Type Code | ||
| ORC.10.12 | Check Digit Scheme | ||
| ORC.10.13 | Identifier Type Code | ||
| ORC.12 | Ordering Provider | ||
| ORC.12.1 | ID Number | ||
| ORC.12.2 | Family Name | ||
| ORC.12.2.1 | Surname | Smith | Test Case Fixed |
| ORC.12.2.2 | Own Surname Prefix | ||
| ORC.12.2.3 | Own Surname | ||
| ORC.12.2.4 | Surname Prefix From Partner/Spouse | ||
| ORC.12.2.5 | Surname From Partner/Spouse | ||
| ORC.12.3 | Given Name | Frank | Test Case Fixed |
| ORC.12.4 | Second and Further Given Names or Initials Thereof | ||
| ORC.12.9 | Assigning Authority | ||
| ORC.12.9.1 | Namespace ID | ||
| ORC.12.9.2 | Universal ID | ||
| ORC.12.9.3 | Universal ID Type | ||
| ORC.12.10 | Name Type Code | L | |
| ORC.12.12 | Check Digit Scheme | ||
| ORC.12.13 | Identifier Type Code | ||
| ORC.17 | Entering Organization | ||
| ORC.17.1 | Identifier | SP | |
| ORC.17.2 | Text | Shoreline Pediatrics | Test Case Fixed |
| ORC.17.3 | Name of Coding System | HL70362 | |
| ORC.17.5 | Alternate Text | ||
| ORC.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20091123 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 08 | |
| RXA.5.2 | Text | hepatitis B vaccine, pediatric or pediatric/adolescent dosage | |
| RXA.5.3 | Name of Coding System | CVX | |
| RXA.5.5 | Alternate Text | ENGERIX-B | |
| RXA.5.6 | Name of Alternate Coding System | NDC | |
| RXA.6 | Administered Amount | 999 | |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | 08 | |
| RXA.9.2 | Text | Historical information - from public agency | |
| RXA.9.3 | Name of Coding System | NIP001 | |
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | Sirtis | |
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | Lisa | |
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | DCS_DC | |
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | 6332FK33 | |
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | 20101214 | |
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | SKB | |
| RXA.17.2 | Text | GlaxoSmithKline Biologicals SA | |
| RXA.17.3 | Name of Coding System | MVX | |
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | CP | |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20150715 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 45 | Test Case Fixed |
| RXA.5.2 | Text | hepatitis B vaccine, unspecified formulation | Test Case Fixed |
| RXA.5.3 | Name of Coding System | CVX | Test Case Fixed |
| RXA.5.5 | Alternate Text | ||
| RXA.5.6 | Name of Alternate Coding System | ||
| RXA.6 | Administered Amount | 999 | Test Case Fixed |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | ||
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | ||
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | ||
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | ||
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | ||
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | ||
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | ||
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | ||
| RXA.17.2 | Text | ||
| RXA.17.3 | Name of Coding System | ||
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | NA | Test Case Fixed |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20150715 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 107 | Test Case Fixed |
| RXA.5.2 | Text | DTaP, unspecified formulation | Test Case Fixed |
| RXA.5.3 | Name of Coding System | CVX | Test Case Fixed |
| RXA.5.5 | Alternate Text | ||
| RXA.5.6 | Name of Alternate Coding System | ||
| RXA.6 | Administered Amount | 999 | Test Case Fixed |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | ||
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | ||
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | ||
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | ||
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | ||
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | ||
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | ||
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | ||
| RXA.17.2 | Text | ||
| RXA.17.3 | Name of Coding System | ||
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | NA | Test Case Fixed |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20150715 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 08 | Test Case Fixed |
| RXA.5.2 | Text | Hib | Test Case Fixed |
| RXA.5.3 | Name of Coding System | CVX | Test Case Fixed |
| RXA.5.5 | Alternate Text | ||
| RXA.5.6 | Name of Alternate Coding System | ||
| RXA.6 | Administered Amount | 999 | Test Case Fixed |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | ||
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | ||
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | ||
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | ||
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | ||
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | ||
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | ||
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | ||
| RXA.17.2 | Text | ||
| RXA.17.3 | Name of Coding System | ||
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | NA | Test Case Fixed |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20150715 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 152 | Test Case Fixed |
| RXA.5.2 | Text | Pneumococcal Conjugate, unspecified formulation | Test Case Fixed |
| RXA.5.3 | Name of Coding System | CVX | Test Case Fixed |
| RXA.5.5 | Alternate Text | ||
| RXA.5.6 | Name of Alternate Coding System | ||
| RXA.6 | Administered Amount | 999 | Test Case Fixed |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | ||
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | ||
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | ||
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | ||
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | ||
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | ||
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | ||
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | ||
| RXA.17.2 | Text | ||
| RXA.17.3 | Name of Coding System | ||
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | NA | Test Case Fixed |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXA.1 | Give Sub-ID Counter | 0 | |
| RXA.2 | Administration Sub-ID Counter | 1 | |
| RXA.3 | Date/Time Start of Administration | ||
| RXA.3.1 | Time | 20150715 | |
| RXA.5 | Administered Code | ||
| RXA.5.1 | Identifier | 122 | Test Case Fixed |
| RXA.5.2 | Text | rotavirus, unspecified formulation | Test Case Fixed |
| RXA.5.3 | Name of Coding System | CVX | Test Case Fixed |
| RXA.5.5 | Alternate Text | ||
| RXA.5.6 | Name of Alternate Coding System | ||
| RXA.6 | Administered Amount | 999 | Test Case Fixed |
| RXA.7 | Administered Units | ||
| RXA.7.1 | Identifier | ||
| RXA.7.2 | Text | ||
| RXA.7.3 | Name of Coding System | ||
| RXA.7.5 | Alternate Text | ||
| RXA.7.6 | Name of Alternate Coding System | ||
| RXA.9 | Administration Notes | ||
| RXA.9.1 | Identifier | ||
| RXA.9.2 | Text | ||
| RXA.9.3 | Name of Coding System | ||
| RXA.9.5 | Alternate Text | ||
| RXA.9.6 | Name of Alternate Coding System | ||
| RXA.10 | Administering Provider | ||
| RXA.10.1 | ID Number | ||
| RXA.10.2 | Family Name | ||
| RXA.10.2.1 | Surname | ||
| RXA.10.2.2 | Own Surname Prefix | ||
| RXA.10.2.3 | Own Surname | ||
| RXA.10.2.4 | Surname Prefix From Partner/Spouse | ||
| RXA.10.2.5 | Surname From Partner/Spouse | ||
| RXA.10.3 | Given Name | ||
| RXA.10.4 | Second and Further Given Names or Initials Thereof | ||
| RXA.10.9 | Assigning Authority | ||
| RXA.10.9.1 | Namespace ID | ||
| RXA.10.9.2 | Universal ID | ||
| RXA.10.9.3 | Universal ID Type | ||
| RXA.10.10 | Name Type Code | ||
| RXA.10.12 | Check Digit Scheme | ||
| RXA.10.13 | Identifier Type Code | ||
| RXA.11 | Administered-at Location | ||
| RXA.11.4 | Facility | ||
| RXA.11.4.1 | Namespace ID | ||
| RXA.11.4.2 | Universal ID | ||
| RXA.11.4.3 | Universal ID Type | ||
| RXA.15 | Substance Lot Number | ||
| RXA.16 | Substance Expiration Date | ||
| RXA.16.1 | Time | ||
| RXA.17 | Substance Manufacturer Name | ||
| RXA.17.1 | Identifier | ||
| RXA.17.2 | Text | ||
| RXA.17.3 | Name of Coding System | ||
| RXA.17.5 | Alternate Text | ||
| RXA.17.6 | Name of Alternate Coding System | ||
| RXA.18 | Substance/Treatment Refusal Reason | ||
| RXA.18.1 | Identifier | ||
| RXA.18.2 | Text | ||
| RXA.18.3 | Name of Coding System | ||
| RXA.18.5 | Alternate Text | ||
| RXA.18.6 | Name of Alternate Coding System | ||
| RXA.20 | Completion Status | NA | Test Case Fixed |
| RXA.21 | Action Code - RXA | A |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| RXR.1 | Route | ||
| RXR.1.1 | Identifier | C28161 | |
| RXR.1.2 | Text | IM | |
| RXR.1.3 | Name of Coding System | NCIT | |
| RXR.1.5 | Alternate Text | IM | |
| RXR.1.6 | Name of Alternate Coding System | HL70162 | |
| RXR.2 | Administration Site | ||
| RXR.2.1 | Identifier | LT | |
| RXR.2.2 | Text | Left Thigh | |
| RXR.2.3 | Name of Coding System | HL70163 | |
| RXR.2.5 | Alternate Text | ||
| RXR.2.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 1 | |
| OBX.2 | Value Type | CE | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 30945-0 | Test Case Fixed |
| OBX.3.2 | Text | Vaccination contraindication | Test Case Fixed |
| OBX.3.3 | Name of Coding System | LN | Test Case Fixed |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 2 | |
| OBX.2 | Value Type | TS | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 30946-8 | Test Case Fixed |
| OBX.3.2 | Text | Vaccination contraindication/precaution effective date | Test Case Fixed |
| OBX.3.3 | Name of Coding System | LN | Test Case Fixed |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.5.1 | Time | 20150715 | |
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 3 | |
| OBX.2 | Value Type | TS | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 30944-3 | Test Case Fixed |
| OBX.3.2 | Text | Vaccination temporary contraindication/precaution expiration date | Test Case Fixed |
| OBX.3.3 | Name of Coding System | LN | Test Case Fixed |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.5.1 | Time | 20150815 | |
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 1 | |
| OBX.2 | Value Type | CE | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 30945-0 | Test Case Fixed |
| OBX.3.2 | Text | Vaccination contraindication | Test Case Fixed |
| OBX.3.3 | Name of Coding System | LN | Test Case Fixed |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 2 | |
| OBX.2 | Value Type | TS | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 30946-8 | Test Case Fixed |
| OBX.3.2 | Text | Vaccination contraindication/precaution effective date | Test Case Fixed |
| OBX.3.3 | Name of Coding System | LN | Test Case Fixed |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.5.1 | Time | 20150715 | |
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 3 | |
| OBX.2 | Value Type | TS | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 30944-3 | Test Case Fixed |
| OBX.3.2 | Text | Vaccination temporary contraindication/precaution expiration date | Test Case Fixed |
| OBX.3.3 | Name of Coding System | LN | Test Case Fixed |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.5.1 | Time | 20150815 | |
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 1 | |
| OBX.2 | Value Type | CE | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 30945-0 | Test Case Fixed |
| OBX.3.2 | Text | Vaccination contraindication | Test Case Fixed |
| OBX.3.3 | Name of Coding System | LN | Test Case Fixed |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 2 | |
| OBX.2 | Value Type | TS | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 30946-8 | Test Case Fixed |
| OBX.3.2 | Text | Vaccination contraindication/precaution effective date | Test Case Fixed |
| OBX.3.3 | Name of Coding System | LN | Test Case Fixed |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.5.1 | Time | 20150715 | |
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 3 | |
| OBX.2 | Value Type | TS | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 30944-3 | Test Case Fixed |
| OBX.3.2 | Text | Vaccination temporary contraindication/precaution expiration date | Test Case Fixed |
| OBX.3.3 | Name of Coding System | LN | Test Case Fixed |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.5.1 | Time | 20150815 | |
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 1 | |
| OBX.2 | Value Type | CE | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 30945-0 | Test Case Fixed |
| OBX.3.2 | Text | Vaccination contraindication | Test Case Fixed |
| OBX.3.3 | Name of Coding System | LN | Test Case Fixed |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 2 | |
| OBX.2 | Value Type | TS | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 30946-8 | Test Case Fixed |
| OBX.3.2 | Text | Vaccination contraindication/precaution effective date | Test Case Fixed |
| OBX.3.3 | Name of Coding System | LN | Test Case Fixed |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.5.1 | Time | 20150715 | |
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 3 | |
| OBX.2 | Value Type | TS | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 30944-3 | Test Case Fixed |
| OBX.3.2 | Text | Vaccination temporary contraindication/precaution expiration date | Test Case Fixed |
| OBX.3.3 | Name of Coding System | LN | Test Case Fixed |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.5.1 | Time | 20150815 | |
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 1 | |
| OBX.2 | Value Type | CE | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 30945-0 | Test Case Fixed |
| OBX.3.2 | Text | Vaccination contraindication | Test Case Fixed |
| OBX.3.3 | Name of Coding System | LN | Test Case Fixed |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 2 | |
| OBX.2 | Value Type | TS | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 30946-8 | Test Case Fixed |
| OBX.3.2 | Text | Vaccination contraindication/precaution effective date | Test Case Fixed |
| OBX.3.3 | Name of Coding System | LN | Test Case Fixed |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.5.1 | Time | 20150715 | |
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Location | Data Element | Data | Categorization |
|---|---|---|---|
| OBX.1 | Set ID - OBX | 3 | |
| OBX.2 | Value Type | TS | |
| OBX.3 | Observation Identifier | ||
| OBX.3.1 | Identifier | 30944-3 | Test Case Fixed |
| OBX.3.2 | Text | Vaccination temporary contraindication/precaution expiration date | Test Case Fixed |
| OBX.3.3 | Name of Coding System | LN | Test Case Fixed |
| OBX.3.5 | Alternate Text | ||
| OBX.3.6 | Name of Alternate Coding System | ||
| OBX.4 | Observation Sub-ID | 1 | |
| OBX.5 | Observation Value | ||
| OBX.5.1 | Time | 20150815 | |
| OBX.6 | Units | ||
| OBX.6.1 | Identifier | ||
| OBX.6.2 | Text | ||
| OBX.6.3 | Name of Coding System | ||
| OBX.6.5 | Alternate Text | ||
| OBX.6.6 | Name of Alternate Coding System | ||
| OBX.11 | Observation Result Status | F | |
| OBX.14 | Date/Time of the Observation | ||
| OBX.14.1 | Time | 20150715 | |
| OBX.17 | Observation Method | ||
| OBX.17.1 | Identifier | ||
| OBX.17.2 | Text | ||
| OBX.17.3 | Name of Coding System | ||
| OBX.17.5 | Alternate Text | ||
| OBX.17.6 | Name of Alternate Coding System |
| Element | Data |
|---|---|
| Patient Name | Mariela Gonzales Morales |
| Mother's Maiden Name | Joanna Gonzales |
| ID Number | 123456 987633 |
| Date/Time of Birth | 03/30/2015 |
| Administrative Sex | Female |
| Patient Address | 3321 Standish Way Stamford CT 06903 USA |
| Patient Address 1 | 325 Shorline Drive Stamford CT 06901 |
| Local Number | (203)555-1214 |
| Race | Other Race |
| Ethnic Group | Hispanic or Latino |
| Birth Order |
| Element | Data |
|---|---|
| Immunization Registry Status | A |
| Immunization Registry Status Effective Date | 07/01/2012 |
| Publicity Code | Reminder/Recall - any method |
| Publicity Code Effective Date | 07/01/2012 |
| Protection Indicator | |
| Protection Indicator Effective Date |
| Element | Data |
|---|---|
| Name | Joanna Gonzales Morales |
| Relationship | Mother |
| Address | 4623 Standish Way Stamford CT 06903 |
| Phone Number | (203)555-1213 |
| Element | Data |
|---|---|
| Administered Code | hepatitis B vaccine, pediatric or pediatric/adolescent dosage |
| Date/Time Start of Administration | 11/23/2009 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | Lisa Sirtis |
| Substance Lot Number | 6332FK33 |
| Substance Expiration Date | 12/14/2010 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Shoreline Hospital |
| Entered By | Lisa Sirtis |
| Ordered By | Jane Carter |
| Element | Data |
|---|---|
| Administered Code | hepatitis B vaccine, unspecified formulation |
| Date/Time Start of Administration | 07/15/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | NA |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Vaccination contraindication | current fever with moderate-to-severe illness |
| Vaccination contraindication/precaution effective date | 07/15/2015 |
| Vaccination temporary contraindication/precaution expiration date | 08/15/2015 |
| Element | Data |
|---|---|
| Administered Code | DTaP, unspecified formulation |
| Date/Time Start of Administration | 07/15/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | NA |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Vaccination contraindication | current fever with moderate-to-severe illness |
| Vaccination contraindication/precaution effective date | 07/15/2015 |
| Vaccination temporary contraindication/precaution expiration date | 08/15/2015 |
| Element | Data |
|---|---|
| Administered Code | Hib |
| Date/Time Start of Administration | 07/15/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | NA |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Vaccination contraindication | current fever with moderate-to-severe illness |
| Vaccination contraindication/precaution effective date | 07/15/2015 |
| Vaccination temporary contraindication/precaution expiration date | 08/15/2015 |
| Element | Data |
|---|---|
| Administered Code | Pneumococcal Conjugate, unspecified formulation |
| Date/Time Start of Administration | 07/15/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | NA |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Vaccination contraindication | current fever with moderate-to-severe illness |
| Vaccination contraindication/precaution effective date | 07/15/2015 |
| Vaccination temporary contraindication/precaution expiration date | 08/15/2015 |
| Element | Data |
|---|---|
| Administered Code | rotavirus, unspecified formulation |
| Date/Time Start of Administration | 07/15/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | NA |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Vaccination contraindication | current fever with moderate-to-severe illness |
| Vaccination contraindication/precaution effective date | 07/15/2015 |
| Vaccination temporary contraindication/precaution expiration date | 08/15/2015 |
| Element | Data |
|---|---|
| Patient Name | Mariela Gonzales Morales |
| Mother's Maiden Name | Joanna Gonzales |
| ID Number | 123456 987633 |
| Date/Time of Birth | 03/30/2015 |
| Administrative Sex | Female |
| Patient Address | 3321 Standish Way Stamford CT 06903 USA |
| Patient Address 1 | 325 Shorline Drive Stamford CT 06901 |
| Local Number | (203)555-1214 |
| Race | Other Race |
| Ethnic Group | Hispanic or Latino |
| Birth Order |
| Element | Data |
|---|---|
| Immunization Registry Status | A |
| Immunization Registry Status Effective Date | 07/01/2012 |
| Publicity Code | Reminder/Recall - any method |
| Publicity Code Effective Date | 07/01/2012 |
| Protection Indicator | |
| Protection Indicator Effective Date |
| Element | Data |
|---|---|
| Name | Joanna Gonzales Morales |
| Relationship | Mother |
| Address | 4623 Standish Way Stamford CT 06903 |
| Phone Number | (203)555-1213 |
| Element | Data |
|---|---|
| Administered Code | hepatitis B vaccine, pediatric or pediatric/adolescent dosage |
| Date/Time Start of Administration | 11/23/2009 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | Lisa Sirtis |
| Substance Lot Number | 6332FK33 |
| Substance Expiration Date | 12/14/2010 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Shoreline Hospital |
| Entered By | Lisa Sirtis |
| Ordered By | Jane Carter |
| Element | Data |
|---|---|
| Administered Code | hepatitis B vaccine, unspecified formulation |
| Date/Time Start of Administration | 07/15/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | NA |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Vaccination contraindication | current fever with moderate-to-severe illness |
| Vaccination contraindication/precaution effective date | 07/15/2015 |
| Vaccination temporary contraindication/precaution expiration date | 08/15/2015 |
| Element | Data |
|---|---|
| Administered Code | DTaP, unspecified formulation |
| Date/Time Start of Administration | 07/15/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | NA |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Vaccination contraindication | current fever with moderate-to-severe illness |
| Vaccination contraindication/precaution effective date | 07/15/2015 |
| Vaccination temporary contraindication/precaution expiration date | 08/15/2015 |
| Element | Data |
|---|---|
| Administered Code | Hib |
| Date/Time Start of Administration | 07/15/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | NA |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Vaccination contraindication | current fever with moderate-to-severe illness |
| Vaccination contraindication/precaution effective date | 07/15/2015 |
| Vaccination temporary contraindication/precaution expiration date | 08/15/2015 |
| Element | Data |
|---|---|
| Administered Code | Pneumococcal Conjugate, unspecified formulation |
| Date/Time Start of Administration | 07/15/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | NA |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Vaccination contraindication | current fever with moderate-to-severe illness |
| Vaccination contraindication/precaution effective date | 07/15/2015 |
| Vaccination temporary contraindication/precaution expiration date | 08/15/2015 |
| Element | Data |
|---|---|
| Administered Code | rotavirus, unspecified formulation |
| Date/Time Start of Administration | 07/15/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | NA |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Vaccination contraindication | current fever with moderate-to-severe illness |
| Vaccination contraindication/precaution effective date | 07/15/2015 |
| Vaccination temporary contraindication/precaution expiration date | 08/15/2015 |
| Following the vaccination visit, the provider uses the EMR to produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.) |
| No Comments |
| Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. New vaccinations have been administered. |
| The patient/parent has been provided a patient immunization history report. |
| Produce Standard Patient Immunization History Report: The EHR or other clinical software system produces a report of a patient's immunization history that is appropriate for various entities, such as schools and day-care centers. |
| No evaluation criteria |
| No Note |
|
Following the vaccination visit, the provider uses the EMR to produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.) |
No Comments |
|
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. New vaccinations have been administered. |
|
The patient/parent has been provided a patient immunization history report. |
|
Produce Standard Patient Immunization History Report: The EHR or other clinical software system produces a report of a patient's immunization history that is appropriate for various entities, such as schools and day-care centers. |
The following patient demographics are displayed: Patient Identifier Number: Vendor Assigned
Patient Identifier Type Code: Vendor Assigned
Patient Name: Juana Mariana Gonzales
Date/Time of Birth: 12/23/2009 11:05am
Sex: Female
Patient Address: 4345 Standish Way, Stamford, CT, 06903
Multiple Birth: N
Birth Order: NA
The following Vaccination History is displayed:
Vaccine Group: Hep B Peds NOS
Administered: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)
ENGERIX-B (NDC 58160-0820-11)"
Date Administered: 12/23/2009
Additional Observations: None
Dose #: 1
Doses in Series: 3
Valid Dose: Y
Ordering Provider: Jane Carter
Entered By: Lisa Sirtis
Entering Organization: Shoreline Hospital
Administered Amt: .05 mL
Administering Provider: Jane Carter
Administered at Location: 325 Shorline Drive,
Stamford Connecticut 06901
Lot#: 6332FK33
Exp Date: 12/14/2010
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
Vaccine Group: Hep B Peds NOS
Administered: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)
ENGERIX-B (NDC 58160-0820-11)"
Date Administered: 1/15/2010
Additional Observations: None
Dose #: 2
Doses in Series: 3
Valid Dose: Y
Ordering Provider: Frank Smith
Entered By: Sandra Molina
Entering Organization: Shoreline Pediatrics
Administered Amt: .05 mL
Administering Provider: Sandra Molina
Administered at Location: 400 Shorline Drive,
Stamford Connecticut 06901
Lot#: 6352FK1
Exp Date: 10/1/2010
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Thigh (HL7 RT)
Vaccine Group: Hep B Peds NOS
Administered: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)
ENGERIX-B (NDC 58160-0820-11)"
Date Administered: 10/30/2010
Additional Observations: None
Dose #: 3
Doses in Series: 3
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: Sandra Molina
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: 6352FK24
Exp Date: 8/31/2012
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)
DAPTACEL (NDC 49281-0286-01)"
Date Administered: 1/22/2010
Additional Observations: None
Dose #: 1
Doses in Series: 5
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: D409QS2341
Exp Date: 11/30/2011
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)
DAPTACEL (NDC 49281-0286-01)
Date Administered: 3/23/2010
Additional Observations: 31044-1 Reaction, VXC12^fever of >40.5C (105F) within 48 hours of dose
Dose #: 2
Doses in Series: 5
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: D409QS2433
Exp Date: 9/4/2011
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Thigh (HL7 RT)
Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)
DAPTACEL (NDC 49281-0286-01)"
Date Administered: 5/22/2010
Additional Observations:
Dose #: 3
Doses in Series: 5
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: D409QS3255
Exp Date: 12/1/2010
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)
DAPTACEL (NDC 49281-0286-01)"
Date Administered: 2/21/2011
Additional Observations:
Dose #: 4
Doses in Series: 5
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: D409QS249
Exp Date: 3/1/2011
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Deltoid (HL7 LD)
Vaccine Group: Hib, unspecified formulation
Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)
PedvaxHIB (NDC 00006-4897-00)"
Date Administered: 1/22/2010
Additional Observations:
Dose #: 1
Doses in Series: 4
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: 7M54K9245
Exp Date: 3/24/2010
Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Thigh (HL7 RT)
Vaccine Group: Hib, unspecified formulation
Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)
PedvaxHIB (NDC 00006-4897-00)"
Date Administered: 3/23/2010
Additional Observations:
Dose #: 2
Doses in Series: 4
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: 7M55K3342
Exp Date: 10/30/2010
Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
Vaccine Group: Hib, unspecified formulation
Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)
PedvaxHIB (NDC 00006-4897-00)"
Date Administered: 5/22/2010
Additional Observations:
Dose #: 3
Doses in Series: 4
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: 7M75K4566
Exp Date: 5/23/2010
Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Thigh (HL7 RT)
Vaccine Group: Hib, unspecified formulation
Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)
PedvaxHIB (NDC 00006-4897-00)"
Date Administered: 2/21/2011
Additional Observations:
Dose #: 4
Doses in Series: 4
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: 7M53K5534
Exp Date: 2/22/2011
Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Deltoid (HL7 LD)
Vaccine Group: poliovirus vaccine, inactivated
Administered: poliovirus vaccine, inactivated (CVX 10)
IPOL (NDC 49281-0860-55)
Date Administered: 1/22/2010
Additional Observations:
Dose #: 1
Doses in Series: 4
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: D333PV2431
Exp Date: 10/4/2010
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Subcutaneous (NCIT C38299, HL70162: SC)
Site: Left Deltoid (HL7 LD)
Vaccine Group: poliovirus vaccine, inactivated
Administered: poliovirus vaccine, inactivated (CVX 10)
IPOL (NDC 49281-0860-55)
Date Administered: 3/23/2010
Additional Observations:
Dose #: 2
Doses in Series: 4
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: D333PV4344
Exp Date: 3/23/2010
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Subcutaneous (NCIT C38299, HL70162: SC)
Site: Left Deltoid (HL7 LD)
Vaccine Group: pneumococcal, unspecified formulation
Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133)
PREVNAR 13 (NDC 00005-1971-05)"
Date Administered: 1/22/2010
Additional Observations:
Dose #: 1
Doses in Series: 4
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: P243V3281
Exp Date: 1/30/2010
Manufacturer: Pfizer, Inc (MVX PFR)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
Vaccine Group: pneumococcal, unspecified formulation
Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133)
PREVNAR 13 (NDC 00005-1971-05)"
Date Administered: 3/23/2010
Additional Observations:
Dose #: 2
Doses in Series: 4
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: P343V8321
Exp Date: 3/30/2010
Manufacturer: Pfizer, Inc (MVX PFR)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
Vaccine Group: pneumococcal, unspecified formulation
Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133)
PREVNAR 13 (NDC 00005-1971-05)"
Date Administered: 5/22/2010
Additional Observations:
Dose #: 3
Doses in Series: 4
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: P853V2164
Exp Date: 8/30/2010
Manufacturer: Pfizer, Inc (MVX PFR)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Thigh (HL7 RT)
Vaccine Group: pneumococcal, unspecified formulation
Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133)
PREVNAR 13 (NDC 00005-1971-05)"
Date Administered: 2/21/2011
Additional Observations:
Dose #: 4
Doses in Series: 4
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: P853V58532
Exp Date: 4/18/2011
Manufacturer: Pfizer, Inc (MVX PFR)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Deltoid (HL7 LD)
Vaccine Group: rotavirus, unspecified formulation
Administered: rotavirus, live, monovalent vaccine (CVX 119)
ROTARIX (NDC 58160-0854-52)"
Date Administered: 1/22/2010
Additional Observations:
Dose #: 1
Doses in Series: 3
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: 1 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: 6359RV533
Exp Date: 2/15/2010
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
Vaccine Group: rotavirus, unspecified formulation
Administered: rotavirus, live, monovalent vaccine (CVX 119)
ROTARIX (NDC 58160-0854-52)"
Date Administered: 3/23/2010
Additional Observations:
Dose #: 2
Doses in Series: 3
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: 1 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: 6359RV932
Exp Date: 5/10/2011
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Thigh (HL7 RT)
Vaccine Group: influenza, unspecified formulation
Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)
FLUZONE QUADRIVALENT (NDC 49281-0514-25)"
Date Administered: 9/25/2010
Additional Observations:
Dose #: 1
Doses in Series: 2
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .25 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: D8043IN8734
Exp Date: 3/12/2011
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
Vaccine Group: influenza, unspecified formulation
Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)
FLUZONE QUADRIVALENT (NDC 49281-0514-25)"
Date Administered: 10/27/2010
Additional Observations:
Dose #: 2
Doses in Series: 2
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .25 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: D8043IN8734
Exp Date: 3/12/2011
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Thigh (HL7 RT)
Vaccine Group: influenza, unspecified formulation
Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)
FLUZONE QUADRIVALENT (NDC 49281-0514-25)"
Date Administered: 10/2/2011
Additional Observations:
Dose #:
Doses in Series:
Valid Dose:
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .25 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: D9334IN9333
Exp Date: 5/22/2012
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Deltoid (HL7 LD)
Vaccine Group: influenza, unspecified formulation
Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)
FLUZONE QUADRIVALENT (NDC 49281-0514-25)"
Date Administered: 11/4/2012
Additional Observations:
Dose #:
Doses in Series:
Valid Dose:
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .25 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: D9553IN2243
Exp Date: 4/30/2012
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Deltoid (HL7 LD)
Vaccine Group: influenza, unspecified formulation
Administered: influenza, live, intranasal, quadrivalent (CVX 149)
FluMist Quadrivalent (NDC 66019-0301-10)"
Date Administered: Current Date
Additional Observations:
Dose #:
Doses in Series:
Valid Dose:
Ordering Provider: Sandra Molina
Entered By: Frank Smith
Entering Organization: Oceanview Pediatrics
Administered Amt: .2 mL
Administering Provider: Sandra Molina
Administered at Location: 400 Shoreline Drive, Stamford Connecticut 06901
Lot#: 8L4B3521
Exp Date: 7/15/2015
Manufacturer: MedImmune,LLC (MVX MED)
Route: Nasal (NCIT C38284), Nasal (HL70162 NS)
Site:
Vaccine Group: Hep A, unspecified formulation
Administered: hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83)
HAVRIX (NDC 58160-0825-52)"
Date Administered: 11/23/2011
Additional Observations:
Dose #: 1
Doses in Series: 2
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: 6359RT33
Exp Date: 1/4/2012
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Deltoid (HL7 RD)
Vaccine Group: Hep A, unspecified formulation
Administered: hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83)
HAVRIX (NDC 58160-0825-52)"
Date Administered: 5/23/2012
Additional Observations:
Dose #: 2
Doses in Series: 2
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: 6359RT48
Exp Date: 9/11/2012
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Deltoid (HL7 LD)
Vaccine Group: MMRV
Administered: measles, mumps, rubella, and varicella virus vaccine (CVX 94)
ProQuad (NDC 00006-4999-00)"
Date Administered: 10/23/2010
Additional Observations:
Dose #:
Doses in Series: 2
Valid Dose: N
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: 7W27V7491
Exp Date: 12/15/2010
Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)
Route: Subcutaneous (NCIT C38299, HL70162: SC)
Site: Left Thigh (HL7 LT)
Vaccine Group: MMRV
Administered: measles, mumps, rubella, and varicella virus vaccine (CVX 94)
ProQuad (NDC 00006-4999-00)"
Date Administered: 11/22/2012
Additional Observations:
Dose #: 1
Doses in Series: 2
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: 7W87V3452
Exp Date: 4/13/2013
Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)
Route: Subcutaneous (NCIT C38299, HL70162: SC)
Site: Left Deltoid (HL7 LD)
Vaccine Group: MMRV
Administered: measles, mumps, rubella, and varicella virus vaccine (CVX 94)
ProQuad (NDC 00006-4999-00)"
Date Administered: Current Date
Additional Observations: Reaction (LOINC 31044-1)/fever of >40.5C (105F) within 48 hours of dose (CDCPHINVS VXC12)
Dose #: 2
Doses in Series: 2
Valid Dose: Y
Ordering Provider: Sandra Molina
Entered By: Frank Smith
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: Sandra Molina
Administered at Location: 400 Shoreline Drive, Stamford Connecticut 06901
Lot#: 7W87V3687
Exp Date: 7/15/2015
Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)
Route: Subcutaneous (NCIT C38299, HL70162: SC)
Site: Left Deltoid (HL7 LD)
The Following Vaccine Forecast is displayed:
Vaccine Group: IPV
Due Date: 11/22/2013
Earliest Date to Give: 11/22/2013
Latest Date to Give: 11/22/2015
Overdue Date: 11/23/2015
Immunization Schedule: ACIP
Vaccine Group: influenza, unspecified formulation
Due Date: 10/21/2016
Earliest Date to Give: 9/1/2016
Latest Date to Give: 2/29/2017
Overdue Date: 3/1/3027
Immunization Schedule: ACIP
|
No Note |
| Following the vaccination visit, the provider uses the EMR to produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.) |
| No Comments |
| Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. New vaccinations have been administered. |
| The patient/parent has been provided a patient immunization history report. |
| Produce Standard Patient Immunization History Report: The EHR or other clinical software system produces a report of a patient's immunization history that is appropriate for various entities, such as schools and day-care centers. |
| No evaluation criteria |
| No Note |
|
Following the vaccination visit, the provider uses the EMR to produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.) |
No Comments |
|
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. New vaccinations have been administered. |
|
The patient/parent has been provided a patient immunization history report. |
|
Produce Standard Patient Immunization History Report: The EHR or other clinical software system produces a report of a patient's immunization history that is appropriate for various entities, such as schools and day-care centers. |
The following patient demographics are displayed:
Patient Identifier Number: Vendor Assigned
Patient Identifier Type Code: Vendor Assigned
Patient Name: Juan Marcel Gonzales
Date/Time of Birth: 11/23/2011 11:00am
Sex: Male
Patient Address: 4623 Standish Way, Stamford, CT 06903
Multiple Birth: N
Birth Order: NA
The following Vaccination History is displayed:
Vaccine Group: Hep B Peds NOS
Administered: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)
ENGERIX-B (NDC 58160-0820-11)"
Date Administered: 11/23/2011
Additional Observations:
Dose #: 1
Doses in Series: 3
Valid Dose: Y
Ordering Provider: Jane Carter
Entered By: Lisa Sirtis
Entering Organization: Shoreline Hospital
Administered Amt: .05 mL
Administering Provider: Jane Carter
Administered at Location: 325 Shorline Drive,
Stamford Connecticut 06901
Lot#: 6332FK34
Exp Date: 12/14/2011
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
Vaccine Group: Hep B Peds NOS
Administered: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)
ENGERIX-B (NDC 58160-0820-11)"
Date Administered: 12/23/2013
Additional Observations:
Dose #: 2
Doses in Series: 3
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: 6352FK2
Exp Date: 10/1/2011
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Thigh (HL7 RT)
Vaccine Group: Hep B Peds NOS
Administered: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)
ENGERIX-B (NDC 58160-0820-11)"
Date Administered: Current Date
Additional Observations:
Dose #: 3
Doses in Series: 3
Valid Dose: Y
Ordering Provider: Sandra Molina
Entered By: Frank Smith
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: Sandra Molina
Administered at Location: 400 Shoreline Drive, Stamford Connecticut 06901
Lot#: 6332FK26
Exp Date: 8/25/2015
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Deltoid (HL70162 LD)
Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)
DAPTACEL (NDC 49281-0286-01)"
Date Administered: 1/22/2012
Additional Observations:
Dose #: 1
Doses in Series: 5
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: D409QS2342
Exp Date: 11/30/2012
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)
DAPTACEL (NDC 49281-0286-01)"
Date Administered: 3/22/2012
Additional Observations:
Dose #: 2
Doses in Series: 5
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: D409QS2434
Exp Date: 9/4/2012
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Thigh (HL7 RT)
Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)
DAPTACEL (NDC 49281-0286-01)"
Date Administered: 5/21/2012
Additional Observations:
Dose #: 3
Doses in Series: 5
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: D409QS3256
Exp Date: 12/1/2012
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)
DAPTACEL (NDC 49281-0286-01)"
Date Administered: 5/21/2012
Additional Observations:
Dose #: 3
Doses in Series: 5
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: D409QS3256
Exp Date: 12/1/2012
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
Vaccine Group: Hib, unspecified formulation
Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)
PedvaxHIB (NDC 00006-4897-00)"
Date Administered: 1/22/2012
Additional Observations:
Dose #: 1
Doses in Series: 4
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: 7M54K9255
Exp Date: 3/24/2012
Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Thigh (HL7 RT)
Vaccine Group: Hib, unspecified formulation
Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)
PedvaxHIB (NDC 00006-4897-00)"
Date Administered: 3/22/2012
Additional Observations:
Dose #: 2
Doses in Series: 4
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: 7M55K3343
Exp Date: 10/30/2012
Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
Vaccine Group: Hib, unspecified formulation
Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)
PedvaxHIB (NDC 00006-4897-00)"
Date Administered: 5/21/2012
Additional Observations:
Dose #: 3
Doses in Series: 4
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: 7M75K4577
Exp Date: 5/23/2012
Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Thigh (HL7 RT)
Vaccine Group: Hib, unspecified formulation
Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)
PedvaxHIB (NDC 00006-4897-00)"
Date Administered: 11/22/2012
Additional Observations:
Dose #: 4
Doses in Series: 4
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: 7M53K5535
Exp Date: 2/22/2012
Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Deltoid (HL7 LD)
Vaccine Group: poliovirus vaccine, inactivated
Administered: poliovirus vaccine, inactivated (CVX 10)
IPOL (NDC 49281-0860-55)"
Date Administered: 1/22/2012
Additional Observations:
Dose #: 1
Doses in Series: 4
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: D333PV2444
Exp Date: 10/4/2012
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Subcutaneous (NCIT C38299, HL70162: SC)
Site: Left Deltoid (HL7 LD)
Vaccine Group: poliovirus vaccine, inactivated
Administered: poliovirus vaccine, inactivated (CVX 10)
IPOL (NDC 49281-0860-55)"
Date Administered: 3/22/2012
Additional Observations:
Dose #: 2
Doses in Series: 4
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: D333PV4343
Exp Date: 3/23/2012
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Subcutaneous (NCIT C38299, HL70162: SC)
Site: Left Deltoid (HL7 LD)
Vaccine Group: poliovirus vaccine, inactivated
Administered: poliovirus vaccine, inactivated (CVX 10)
IPOL (NDC 49281-0860-55)
Date Administered: 5/21/2012
Additional Observations:
Dose #: 2
Doses in Series: 4
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: D335PV9654
Exp Date: 2/22/2013
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Subcutaneous (NCIT C38299, HL70162: SC)
Site: Left Deltoid (HL7 LD)
Vaccine Group: pneumococcal, unspecified formulation
Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133)
PREVNAR 13 (NDC 00005-1971-05)"
Date Administered: 1/22/2012
Additional Observations:
Dose #: 1
Doses in Series: 4
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: P243V3321
Exp Date: 1/30/2012
Manufacturer: Pfizer, Inc (MVX PFR)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
Vaccine Group: pneumococcal, unspecified formulation
Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133)
PREVNAR 13 (NDC 00005-1971-05)"
Date Administered: 3/22/2012
Additional Observations:
Dose #: 2
Doses in Series: 4
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: P343V8445
Exp Date: 3/30/2012
Manufacturer: Pfizer, Inc (MVX PFR)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
Vaccine Group: pneumococcal, unspecified formulation
Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133)
PREVNAR 13 (NDC 00005-1971-05)"
Date Administered: 5/21/2012
Additional Observations:
Dose #: 3
Doses in Series: 4
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: P853V2175
Exp Date: 8/30/2012
Manufacturer: Pfizer, Inc (MVX PFR)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Thigh (HL7 RT)
Vaccine Group: pneumococcal, unspecified formulation
Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133)
PREVNAR 13 (NDC 00005-1971-05)"
Date Administered: 11/22/2012
Additional Observations:
Dose #: 4
Doses in Series: 4
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: P853V58544
Exp Date: 4/18/2013
Manufacturer: Pfizer, Inc (MVX PFR)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Deltoid (HL7 LD)
Vaccine Group: rotavirus, unspecified formulation
Administered: rotavirus, live, monovalent vaccine (CVX 119)
ROTARIX (NDC 58160-0854-52)"
Date Administered: 1/22/2012
Additional Observations:
Dose #: 1
Doses in Series: 3
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: 1 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: 6359RV533
Exp Date: 2/15/2010
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
Vaccine Group: rotavirus, unspecified formulation
Administered: rotavirus, live, monovalent vaccine (CVX 119)
ROTARIX (NDC 58160-0854-52)"
Date Administered: 3/22/2012
Additional Observations:
Dose #: 2
Doses in Series: 3
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: 1 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: 6359RV932
Exp Date: 5/10/2011
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Thigh (HL7 RT)
Vaccine Group: influenza, unspecified formulation
Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)
FLUZONE QUADRIVALENT (NDC 49281-0514-25)"
Date Administered: 9/22/2012
Additional Observations:
Dose #: 1
Doses in Series: 2
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .25 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: D8043IN8734
Exp Date: 3/12/2013
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
Vaccine Group: influenza, unspecified formulation
Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)
FLUZONE QUADRIVALENT (NDC 49281-0514-25)"
Date Administered: 10/20/2012
Additional Observations:
Dose #: 2
Doses in Series: 2
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .25 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: D8043IN8798
Exp Date: 3/12/2013
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Thigh (HL7 RT)
Vaccine Group: influenza, unspecified formulation
Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)
FLUZONE QUADRIVALENT (NDC 49281-0514-25)"
Date Administered: 10/30/2013
Additional Observations:
Dose #:
Doses in Series:
Valid Dose:
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .25 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: D8043IN8734
Exp Date: 5/22/2014
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Deltoid (HL7 LD)
Vaccine Group: influenza, unspecified formulation
Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)
FLUZONE QUADRIVALENT (NDC 49281-0514-25)"
Date Administered: Current Date
Additional Observations:
Dose #:
Doses in Series:
Valid Dose:
Ordering Provider: Sandra Molina
Entered By: Frank Smith
Entering Organization: Oceanview Pediatrics
Administered Amt: .25 mL
Administering Provider: Sandra Molina
Administered at Location: 400 Shoreline Drive, Stamford Connecticut 06901
Lot#: D8043IN8855
Exp Date: 7/28/2015
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
Vaccine Group: Hep A, unspecified formulation
Administered: hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83)
HAVRIX (NDC 58160-0825-52)"
Date Administered: 5/21/2013
Additional Observations:
Dose #: 1
Doses in Series: 2
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: 6359RT35
Exp Date: 1/4/2014
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Deltoid (HL7 RD)
Vaccine Group: Hep A, unspecified formulation
Administered: hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83)
HAVRIX (NDC 58160-0825-52)"
Date Administered: 12/1/2013
Additional Observations:
Dose #: 2
Doses in Series: 2
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: 6359RT47
Exp Date: 9/11/2013
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Deltoid (HL7 LD)
Vaccine Group: MMRV
Administered: measles, mumps, rubella, and varicella virus vaccine (CVX 94)
ProQuad (NDC 00006-4999-00)"
Date Administered: 11/22/2012
Additional Observations:
Dose #: 1
Doses in Series: 2
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: 7W27V7632
Exp Date: 12/15/2016
Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)
Route: Subcutaneous (NCIT C38299, HL70162: SC)
Site: Left Thigh (HL7 LT)
The Following Vaccine Forecast is displayed:
Vaccine Group: Dtap
Due Date: 11/22/2015
Earliest Date to Give: 11/22/2015
Latest Date to Give: 11/21/2017
Overdue Date: 11/22/2017
Immunization Schedule: ACIP
Vaccine Group: IPV
Due Date: 11/22/2015
Earliest Date to Give: 11/22/2015
Latest Date to Give: 11/21/2017
Overdue Date: 11/22/2017
Immunization Schedule: ACIP
Vaccine Group: Influenza
Due Date: 10/22/2015
Earliest Date to Give: 9/1/2015
Latest Date to Give: 1/31/2016
Overdue Date: 2/1/2016
Immunization Schedule: ACIP
Vaccine Group: MMR
Due Date: 11/22/2015
Earliest Date to Give: 11/22/2015
Latest Date to Give: 11/21/2017
Overdue Date: 11/22/2017
Immunization Schedule: ACIP
Vaccine Group: Varicella
Due Date: 11/22/2015
Earliest Date to Give: 11/22/2015
Latest Date to Give: 11/21/2017
Overdue Date: 11/22/2017
Immunization Schedule: ACIP
|
No Note |
| Following the vaccination visit, the provider uses the EMR to produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.) |
| No Comments |
| Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. New vaccinations have been administered. |
| The patient/parent has been provided a patient immunization history report. |
| Produce Standard Patient Immunization History Report: The EHR or other clinical software system produces a report of a patient's immunization history that is appropriate for various entities, such as schools and day-care centers. |
| No evaluation criteria |
| No Note |
|
Following the vaccination visit, the provider uses the EMR to produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.) |
No Comments |
|
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. New vaccinations have been administered. |
|
The patient/parent has been provided a patient immunization history report. |
|
Produce Standard Patient Immunization History Report: The EHR or other clinical software system produces a report of a patient's immunization history that is appropriate for various entities, such as schools and day-care centers. |
The following patient demographics are displayed:
Patient Identifier Number: Vendor Supplied
Patient Identifier Type Code: Vendor Supplied
Patient Name: Mariela Gonzales Morales
Date/Time of Birth: 03/30/2015 11:00am
Sex: Female
Patient Address: 3321 Standish Way, Stamford, CT 06903
Multiple Birth: Y
Birth Order: 1
The following Vaccination History is displayed:
Vaccine Group: Hep B Peds NOS
Administered: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)
ENGERIX-B (NDC 58160-0820-11)"
Date Administered: 11/23/2011
Additional Observations:
Dose #: 1
Doses in Series: 3
Valid Dose: Y
Ordering Provider: Jane Carter
Entered By: Lisa Sirtis
Entering Organization: Shoreline Hospital
Administered Amt: .05 mL
Administering Provider: Jane Carter
Administered at Location: 325 Shorline Drive,
Stamford Connecticut 06901
Lot#: 6332FK34
Exp Date: 12/14/2011
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
The Following Vaccine Forecast is displayed:
Vaccine Group: Hep B Peds NOS
Due Date: 6/29/2015
Earliest Date to Give: 6/29/2015
Latest Date to Give: 7/29/2015
Overdue Date: 7/30/2015
Immunization Schedule: ACIP
Vaccine Group: Dtap
Due Date: 7/29/2015
Earliest Date to Give: 29-Jul-15
Latest Date to Give:
Overdue Date:
Immunization Schedule: ACIP
Vaccine Group: Hib
Due Date: 7/29/2015
Earliest Date to Give: 7/29/2015
Latest Date to Give:
Overdue Date:
Immunization Schedule: ACIP
Vaccine Group: IPV
Due Date: 7/29/2015
Earliest Date to Give: 7/29/2015
Latest Date to Give:
Overdue Date:
Immunization Schedule: ACIP
Vaccine Group: Pneumococcal conjugate
Due Date: 7/29/2015
Earliest Date to Give: 7/29/2015
Latest Date to Give:
Overdue Date:
Immunization Schedule: ACIP
Vaccine Group: Rotavirus
Due Date: 7/29/2015
Earliest Date to Give: 7/29/2015
Latest Date to Give:
Overdue Date:
Immunization Schedule: ACIP
Vaccine Group: Influenza
Due Date: Nov 26, 2015 or later
later
Earliest Date to Give: Nov 26, 2015
Latest Date to Give:
Overdue Date:
Immunization Schedule: ACIP
Vaccine Group: HepA
Due Date: 5/29/2016
Earliest Date to Give: 5/29/2016
Latest Date to Give: 5/29/2017
Overdue Date: 5/30/2017
Immunization Schedule: ACIP
Vaccine Group: MMR
Due Date: 5/29/2016
Earliest Date to Give: 5/29/2016
Latest Date to Give: 8/27/2016
Overdue Date: 8/28/2016
Immunization Schedule: ACIP
Vaccine Group: Varicella
Due Date: 5/29/2016
Earliest Date to Give: 5/29/2016
Latest Date to Give: 8/27/2016
Overdue Date: 8/28/2016
Immunization Schedule: ACIP
|
No Note |
The provider periodically uses the EMR to identify the cohort of patients that are overdue for immunizations along with their contact information in order to send reminder notifications to the patients/parents. |
No Comments |
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. The vaccine forecast is available to the EMR. |
The Cohort report for all patients that are overdue for immunizations is available to the provider through the EMR. |
Produce Population-Level Report: The EHR or other clinical system generates aggregate, population-level reports based on known patient immunization data. |
The following patient information is provided on the cohort report:
|
No Note |
The provider periodically uses the EMR to identify the cohort of patients that are overdue for immunizations along with their contact information in order to send reminder notifications to the patients/parents.
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No Comments |
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. The vaccine forecast is available to the EMR.
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The Cohort report for all patients that are overdue for immunizations is available to the provider through the EMR. |
Produce Population-Level Report: The EHR or other clinical system generates aggregate, population-level reports based on known patient immunization data. |
The following patient information is provided on the cohort report:
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No Note |